280 REVIEWS AND NOTICES OF BOOKS. months after the operation. His only complaint now is that the joint feels a little weak at the sides. He does not find it necessary to wear a bandage or knee-cap. There is very little in text-books of surgery on the subject of separation or fracture of the tubercle of the tibia. The universal recommendation is to wire, screw, or peg the fragment into place. In this case it was impossible to carry out any of these directions, but it was a very simple matter to get the fragments into perfect position in the manner described. Shanghai. PLACENTA PRÆVIA CENTRALIS. BY WILLIAM ROBERTSON, M.D. GLASG. I HAD slight notice of the probable condition of the following case from the husband, who told me that his wife (European) had had hemorrhage three or four times during her present pregnancy. The patient, aged 36, who was in her sixth pregnancy, " felt life," and had no untoward experience beyond the slight haemorrhages referred to. These were controlled by bromide and ergot, and rest in bed. I had no opportunity of vaginal examination until finally being called in for accouche- ment. The pregnancy had reached full term, and foetal life was distinct. Vaginal examination showed a centrally placed placenta prsevia. The os was of the size of a crown-piece, thin, soft, and dilateable. Examination brought away a little blood. Prudence seemed to indicate plugging. The mother was anaemic, with not too good a pulse. Previous labours were normal and not prolonged. Plugging was performed manually without distress or much shock. After a good rest and nourishment the plugs were removed and found only stained. The os was still further dilated. Under chloroform internal version was performed. The placenta was found to be very thin, so that the waters and the head, not yet engaged, could be readily felt. A foot was brought down and the child, a large one, was safely turned. Before the head was engaged the placenta came away entire. An effort was made to deliver the child as rapidly as possible, but the head stuck and delayed delivery for half an hour. The child’s head was 14 inches in circumference and the mother was of small build. The child was born dead, as was to be expected. The mother now required all attention. She had become pale, faint, and pulseless, but answered to the usual restoratives. Very little blood was lost during manipulations and none after- wards. A few tabloids of salt and citrate were placed on the placental area. Recovery was rapid and uneventful. One might have thought of perforating the placenta, allowing the waters to escape, and letting the case proceed in the usual wav. The child’s head would, however, at once have put the whole placenta out of functioning, and besides the length and shock of labour would have invalidated the life of the mother, and certainly the life of the child. Version therefore seemed to offer a chance for both. The slight hold the placenta had on the cervix was disconcerting. I made no effort to detach it beyond perforating it for version, which was an easy matter. The arm in the os pre- vented a too rapid loss of the waters and facilitated seizure of a foot. The placenta came away, of course, completely shorn of membranes. These had to be subsequently very carefully removed. St. Mark’s, Cape Province, South Africa. CONVALESCENT HOME AT GRANGE-OVER-SANDS.- On August 7th Mr. Charles Duncan, M.P., opened the new convalescent home of the Workmen’s Clubs Union which has been erected at a cost of o!ò20,OOO at Grange-over-Sands. The building will accommodate 66 residents. EDINBURGH ROYAL INFIRMARY : THE APPOINTMENT OF SENIOR STUDENTS TO RESIDENT POSTS.-At a meeting of the managers of the Edinburgh Royal Infirmary held on August 7th the following appointments were made :- Resident physicians: James M. Tyrrell, final-year student, to Sir Robert Philip, and Harold Budler, final-year student, to Professor W. Russell. Resident surgeons : Gerald W. Grant, final-year student, to Professor F. M. Caird; J. McAuslin, final-year student, to Mr. N. T. Brewis; Adam Prentice, to Mr. D. Wallace; Duncan Cook, final-year student, to Mr. F. E. Jardine. Surgical out-patient department: John Allison and J. Laurie Lamont, both final-year students, to Mr. Jardine Reviews and Notices of Books. Pathological Lying, Accusation, and Szvindlizg A Study in Fo7°ensic Psychology. By WILLIAM HEALEY, A.B., M.D., Director, Psycho- pathic Institute, Juvenile Court, Chicago, Associate Pro- fessor, Nervous and Mental Diseases, Chicago Polyclinic ; and MARY TENNEY HEALEY, B.L. London: William Heinemann. 1916. Pp. 287. Price 10s. 6d. net. THE main purpose of this work is to establish a " closer definition of pathological lying than has hitherto been offeree. " The authors evidently assume that the existence of such an entity is generally accepted, but contend that previous writers have employed an insufficiently clear termin- ology, and have erroneously included under this heading cases of epilepsy, insanity, and mental defect. They regard "pathological lying" as a "type of delinquency," " and at the outset of their book essay to define it as " falsification, entirely disproportionate to any discernible end in view, engaged in by a person who, at the time of observation, cannot definitely be declared insane, feeble-minded, or epileptic. Such lying manifests itself, most frequently by far, over a period of years or even a life-time." In the course of the introductory chapter it is stated that lawyers or other professional specialists have slight knowledge of this subject, and that one reason for this slight knowledge is the fact that almost nothing has been written on it in English. The second chapter gives some account of much German, and a little French, literature on the subject, and we learn from this that the generally accepted term in Germany for "pathological lying" is pseudologia phantastioa-a term that at least in this context is not luciferous. After a careful perusal of the book before us, which unquestionably contains many faithful and really interesting reports of such cases as are well known to medical psycho- logists conversant with children or " delinquents," or with both of these groups, we are unable to attribute any scientific or practical value to the conception of pseudologiaphantastica in its relation either to psychology, criminology, or penology. It appears to us that the very definition laid down by the authors, and the terms used by them in other parts of the book, imply that they regard insanity and mental defect as concerned with the intellect alone. The cases of "pathological lying " which they appear to regard rightly as essentially consisting in disorder of conduct, are explicitly excluded from the class of " insane " persons because of the absence of delusions, and from the class of ’’ mental defec- tives," or feeble-minded, because, according to the value given to these terms by the authors, the word mind excludes all mental factors other than that of the intellect. If, then, the disorder of conduct which is inseparable from the conception of I I pathological lying," as presented to us in this book, is to be regarded as a type of ’’ delinquency" unconnected with any disorder of intellect, or indeed with discoverable disorder of any kind, whether " mental " or " physical." it follows that the creation of a closely defined class of delinquents under the title of pathological liars is by no means helpful, but, on the contrary, both confusing and meaningless. It seems to us that most of the cases so vividly described in this book are easily referable to mental disorder, from ’’ insanity " to "mental defect " in its various expressions, and especially to the certainly ill-named but justly recognised category of "moral imbeciles," or persons who inherently lack the capacity of being duly educated for social life in spite of fair general intelligence. Undue multiplication of ill-defined classes under new names is greatly to be deprecated, especially in con- nexion with matters that have a practical bearing. The study of disorders of conduct supplies the basic test of mental disorder of all kinds, whether such disorder be styled 11 insanity " or 11 mental defect" ; it underlies, moreover, the problems of grading criminal responsibility and of the appropriate treatment of criminals. The authors of this book, indeed, appear to appreciate in some degree the difficulty of making a I I close definition of pathological lying by inserting a chapter on borderland cases; but they have distinctly failed to establish the contention that their specially defined pathological liars are" mentally normal."
280 REVIEWS AND NOTICES OF BOOKS.
months after the operation. His only complaint now is thatthe joint feels a little weak at the sides. He does not find itnecessary to wear a bandage or knee-cap.
There is very little in text-books of surgery on the subjectof separation or fracture of the tubercle of the tibia. Theuniversal recommendation is to wire, screw, or peg thefragment into place. In this case it was impossible to carryout any of these directions, but it was a very simple matterto get the fragments into perfect position in the mannerdescribed.
PLACENTA PRÆVIA CENTRALIS.
BY WILLIAM ROBERTSON, M.D. GLASG.
I HAD slight notice of the probable condition of the followingcase from the husband, who told me that his wife (European)had had hemorrhage three or four times during her presentpregnancy.The patient, aged 36, who was in her sixth pregnancy, " felt
life," and had no untoward experience beyond the slighthaemorrhages referred to. These were controlled by bromideand ergot, and rest in bed. I had no opportunity of vaginalexamination until finally being called in for accouche-ment. The pregnancy had reached full term, and foetal lifewas distinct. Vaginal examination showed a centrallyplaced placenta prsevia. The os was of the size of acrown-piece, thin, soft, and dilateable. Examinationbrought away a little blood. Prudence seemed toindicate plugging. The mother was anaemic, with not toogood a pulse. Previous labours were normal and notprolonged. Plugging was performed manually withoutdistress or much shock. After a good rest and nourishmentthe plugs were removed and found only stained. The os wasstill further dilated. Under chloroform internal version wasperformed. The placenta was found to be very thin, so thatthe waters and the head, not yet engaged, could be readilyfelt. A foot was brought down and the child, a large one,was safely turned. Before the head was engaged the placentacame away entire. An effort was made to deliver the childas rapidly as possible, but the head stuck and delayeddelivery for half an hour. The child’s head was 14 inches incircumference and the mother was of small build. Thechild was born dead, as was to be expected. The mothernow required all attention. She had become pale, faint, andpulseless, but answered to the usual restoratives. Verylittle blood was lost during manipulations and none after-wards. A few tabloids of salt and citrate were placed on theplacental area. Recovery was rapid and uneventful.One might have thought of perforating the placenta,
allowing the waters to escape, and letting the case proceedin the usual wav. The child’s head would, however, at oncehave put the whole placenta out of functioning, and besidesthe length and shock of labour would have invalidated thelife of the mother, and certainly the life of the child.Version therefore seemed to offer a chance for both. The
slight hold the placenta had on the cervix was disconcerting.I made no effort to detach it beyond perforating it forversion, which was an easy matter. The arm in the os pre-vented a too rapid loss of the waters and facilitated seizureof a foot. The placenta came away, of course, completelyshorn of membranes. These had to be subsequently verycarefully removed.
St. Mark’s, Cape Province, South Africa.
CONVALESCENT HOME AT GRANGE-OVER-SANDS.-On August 7th Mr. Charles Duncan, M.P., opened the newconvalescent home of the Workmen’s Clubs Union which hasbeen erected at a cost of o!ò20,OOO at Grange-over-Sands. Thebuilding will accommodate 66 residents.
EDINBURGH ROYAL INFIRMARY : THE APPOINTMENTOF SENIOR STUDENTS TO RESIDENT POSTS.-At a meetingof the managers of the Edinburgh Royal Infirmary held onAugust 7th the following appointments were made :-Resident physicians: James M. Tyrrell, final-year student,to Sir Robert Philip, and Harold Budler, final-year student,to Professor W. Russell. Resident surgeons : Gerald W. Grant,final-year student, to Professor F. M. Caird; J. McAuslin,final-year student, to Mr. N. T. Brewis; Adam Prentice, toMr. D. Wallace; Duncan Cook, final-year student, to Mr.F. E. Jardine. Surgical out-patient department: JohnAllison and J. Laurie Lamont, both final-year students, toMr. Jardine
Reviews and Notices of Books.Pathological Lying, Accusation, and Szvindlizg A
Study in Fo7°ensic Psychology.By WILLIAM HEALEY, A.B., M.D., Director, Psycho-pathic Institute, Juvenile Court, Chicago, Associate Pro-fessor, Nervous and Mental Diseases, Chicago Polyclinic ;and MARY TENNEY HEALEY, B.L. London: WilliamHeinemann. 1916. Pp. 287. Price 10s. 6d. net.THE main purpose of this work is to establish a
" closerdefinition of pathological lying than has hitherto beenofferee. " The authors evidently assume that the existenceof such an entity is generally accepted, but contend thatprevious writers have employed an insufficiently clear termin-ology, and have erroneously included under this headingcases of epilepsy, insanity, and mental defect. They regard"pathological lying" as a "type of delinquency," " and at theoutset of their book essay to define it as
" falsification,entirely disproportionate to any discernible end in view,engaged in by a person who, at the time of observation,cannot definitely be declared insane, feeble-minded, or
epileptic. Such lying manifests itself, most frequently byfar, over a period of years or even a life-time." In thecourse of the introductory chapter it is stated that lawyersor other professional specialists have slight knowledge of thissubject, and that one reason for this slight knowledge is thefact that almost nothing has been written on it in English.The second chapter gives some account of much German, anda little French, literature on the subject, and we learn fromthis that the generally accepted term in Germany for
"pathological lying" is pseudologia phantastioa-a termthat at least in this context is not luciferous.
After a careful perusal of the book before us, whichunquestionably contains many faithful and really interestingreports of such cases as are well known to medical psycho-logists conversant with children or " delinquents," or withboth of these groups, we are unable to attribute any scientificor practical value to the conception of pseudologiaphantasticain its relation either to psychology, criminology, or penology.It appears to us that the very definition laid down bythe authors, and the terms used by them in other partsof the book, imply that they regard insanity and mentaldefect as concerned with the intellect alone. The cases of
"pathological lying " which they appear to regard rightly asessentially consisting in disorder of conduct, are explicitlyexcluded from the class of " insane " persons because of theabsence of delusions, and from the class of ’’ mental defec-tives," or feeble-minded, because, according to the value
given to these terms by the authors, the word mindexcludes all mental factors other than that of the intellect.If, then, the disorder of conduct which is inseparable fromthe conception of I I pathological lying," as presentedto us in this book, is to be regarded as a typeof ’’ delinquency" unconnected with any disorder ofintellect, or indeed with discoverable disorder of anykind, whether " mental " or " physical." it follows that thecreation of a closely defined class of delinquents under thetitle of pathological liars is by no means helpful, but, onthe contrary, both confusing and meaningless. It seems tous that most of the cases so vividly described in this bookare easily referable to mental disorder, from ’’ insanity " to"mental defect " in its various expressions, and especiallyto the certainly ill-named but justly recognised category of"moral imbeciles," or persons who inherently lack the
capacity of being duly educated for social life in spite offair general intelligence.Undue multiplication of ill-defined classes under new
names is greatly to be deprecated, especially in con-
nexion with matters that have a practical bearing. The
study of disorders of conduct supplies the basic test ofmental disorder of all kinds, whether such disorder be styled11 insanity " or 11 mental defect" ; it underlies, moreover, theproblems of grading criminal responsibility and of the
appropriate treatment of criminals. The authors of thisbook, indeed, appear to appreciate in some degree thedifficulty of making a I I close definition of pathological lyingby inserting a chapter on borderland cases; but theyhave distinctly failed to establish the contention that theirspecially defined pathological liars are" mentally normal."
281REVIEWS AND NOTICES OF BOOKS.
History of the Royal College of Surgeons in Irelandand of the Irish Schools of Medicine, in-
cluding a Medical Bibliography and a M edwalBiography.
By Sir CHARLES A. CAMERON, C.B. Second edition,revised and enlarged. London : Simpkin, Marshall, andCo.; Dublin : Fannin and Co.; Edinburgh : J. Thin. 1916.
Pp. 882.THE history of the corporations of their own profession is,
or should be, always of interest to medical men, and SirCharles Cameron’s History of the Royal College of Surgeonsin Ireland" is a case in point, and a book made all themore attractive by its very discursiveness, for the inclusionof medical bibliography and biography affords its author
great scope for giving his readers many lifelike picturesof past times. To deal first with the history of the
College. The Irish surgeons were primarily, like theirbrethren in other lands, incorporated with the barbers,and a Guild of Barbers was established by Henry VI.in Dublin in the year 1446 on St. Luke’s day, theGuild being established for the promotion and exerciseof the art of chirurgery. By Elizabeth’s time there weresurgeons in Dublin who were not incorporated with thebarbers, but formed a society by themselves. This societywas ordered, 1577, by a charter of the Queen to be incor-porated with that of the barbers. It is worthy of note thatHenry’s charter provided for the admission of women.Another charter was granted by James II. in 1687. In 1780the Dublin Society of Surgeons resolved to apply for acharter incorporating the surgeons of Dublin into a RoyalCollege. Naturally the barber surgeons objected, but thecharter was granted all the same in 1784, and the firstPresident of the Royal College was Samuel Croker-King, whowas also notable for having saved the life of a child whoafterwards became the great Duke of Wellington. A secondcharter was granted in 1829, the most important feature ofwhich was the giving powers to the College to admit toexamination candidates who were not indentured apprentices.Supplemental charters were granted in 1844 and 1885.For the general medical reader the most interesting portions
of Sir Charles Cameron’s work will probably be the biographicaland bibliographical sections. In 1775 John Gilborne, M.D.,wrote the Medical Review : a Poem ; being a Panegyric onthe Faculty of Dublin, Physicians, Surgeons, and Apothecariesmarching in procession to the Temple of Fame." From this
poem Sir Charles Cameron quotes extensively. Though wecannot say that the divine fire is present, yet the bard
certainly succeeds in drawing a striking portrait-The fractur’d Skull, to Samuel Croker-King,The broken Limb, Wounds, and Luxations bring;There’s no Disaster but he can set right,With Splints, Trepan, and Bandage not too tight."
There is one blemish to which we must refer in an other-wise admirable book, and that is the extraordinary numberof misprints, especially in Latin passages. Nearly everyLatin title of a book quoted has at least one misprint, andsome have three or four, while even such a well-worn tag as"Nonomnis moriar appears as Non omnis morior."
" Inother places we find I I carundem " for ".earundem," ‘° com-plarium" for complurium, Ii templina" for I templum," "and "parulus" instead of, we imagine, paratus.
" Sucherrors should not appear in any book, least of all one dealingwith a learned body and in a revised edition.
CURRENT GERMAN MEDICINE.
Wmsnds of the Larynx.-We are indebted to Dr. DundasGrant for a translation of Professor Korner’s (Rostock)article dealing with three cases of gunshot injury of thelarynx (Zeitsohr. f. Ohrenheilk, March, 1915).CASE 1. Shot through larynx and pharynx below voval cords from
right and in front to the left &acM’(M’s.—There was no pain, but loss ofvoice at the time (August 28th). There was some throwing up of bloodwithout cough, and for six days pain on swallowing. The left vocal cordand arytenoid cartilage were almost in the middle line, both on respi-ration and phonation. Below the commisbure, especially to the right.there was a greyish-red, somewhat hummocky swelling. The shot musthave been directly under the left arytenoid cartilage. The conditiongradually settled down, and on Oct. 16th the movements of the arytenoidcartilage and vocal cords were quite normal; the irregular swellingunder the commissure had become converted into a cicatrix in the formof ahorizontal, sharp-edged, fold-like structure which projected for about2 mm. into the lumen of the larynx.Professor Korner’s comment is as follows : This was a
.shot through the larynx and hypo-pharynx. A small
infantry bullet had passed from in front through the thyroidcartilage somewhat on the right of the middle line, imme-diately under the commissure of the vocal cords. It left thelarynx below the left crico-arytenoid joint; it must haveperforated the wall of the hypo-pharynx on the left side infront and behind in order then to leave the body belowthe nape of the neck. We cannot tell whether theball took in with it portions of the collar of the uniform.The results were Eimply a temporary fixation of the leftarytenoid cartilage and a small scar under the commissure.Nothing which the experience of previous wars would haveled us to expect as the inevitable result of such an injurywas present; there was no great haemorrhage, no extensivedestruction of cartilage, and no dangerous oedema. Theprophylactic tracheotomy, which was formerly so stronglyrecommended, was not carried out, and the result showedthat in this case it would have been quite superfluous.CASE 2. Shot on the right side through the lower jccw recovery with
ankylosis of the right crico-aryteitoid joint.-The soldier was shot onSept 16tb, 600 metres distance, through the right horizontal portionof the lower jaw and the right side of the neck, as he had bentforwards in order to lie down. At the moment of injury he observeda singing and humming noise in the head ; he fell forwards and for ashort time was quite deafened. A soldier fastened the firbt dressing onthe orifice of entrance, but no orifice of exit could be seen. Later, whenhe got to the dressing-station, the exit was found and bandaged.Immediately after the shot the voice was weak and hoarse, but therewas no dyspncea nor expectoration of blood. On the other hand, therewas a slight pain on the right side of the neck during swallowing, andthe mouth could not be properly opened, while chewing was impossible,and there was a feeling of numbness of the right side of the lower jaw.He was kept for a week and a half in a hospital and then treated in agarrison hospital at Rostock. On Oct. 12th-that is, 26 days after thewound-Professor Korner saw him for the first time and found him illgood condition, except for the pain on opening the mouth andchewing and the hoarseness. The orifice of entrance was 12 mm.laterally distant from the right corner of the mouth and about3 mm. below the level of the junction of the lips. The orifice ofexit. which was not yet completely healed, was 3 em. to the rightof the spinous process of the seventh cervical vertebra; it was
about 3 em. across. About the middle of the horizontal part of thelower jaw on the right there was a thickening of the bone perceptibleto sight and touch and somewhat tender; although the mouth couldnot be widely opened, it was still possible to inspect the buccal cavityand meso-pharynx, as well as to carry out indirect laryngoscopy. Inter-nally there was no abnormality in the lower jaw. All the teeth werepresent and were sound. The structures of the palate were normaland the tongue movable in all directions. The right vocal cord wasimmovable tu the middle line during both respiration and phonation ;its edge was quite straight; the right arytenoid cartilage showed ncmovements and did not hang forwards; otherwise the picture of thelarynx was completely normal; there was no swelling or extravasationof blood. On the left side the movements of the arytenoid cartilageand vocal cord were unimpaired. The voice sounded somewhat thick,and on inquiry the wounded man stated that he noticed a slight difficultyin breathing on exertion. To the touch externally the larynx showedno difference between the right and the left sides, but there was sometenderness on pressure on the posterior part of the right half of thethyroid cartilage. The muscles supplied by the right spinal accessorynerve were unaffected. An X ray examination of the lower jaw revealeda grooved fracture running obliquely backwards and inwards, but withoutaffecting the roots of the teeth. On Oct. 30th the laryngoscopic appear-ance was unchanged, the voice was quite clear, the mouth could beopened, while the swelling of the jaw was scarcely to be detected, andthe orifice of exit had healed.
The author comments: This was a subcutaneous glancingshot on the right side of the larynx; it injured the posteriorpart of the right half of the thyroid cartilage; with thisthere was a lasting fixation of the right crico-arytenoid joint,as the result of which the vocal cords stayed in the middleline. The shot does not seem to have gone to the hypo-pharynx, as no trace of blood was expelled. The fact thatthe median position of the vocal cord did not depend uponan injury of the vagus nerve was shown by the fact that thearytenoid cartilage was not inclined forwards, and 44 daysafter the injury there was no concavity of the border of thevocal cords. An isolated injury of the trunk of the vagus sohigh up without injury of the great vessels or the otherneighbouring cranial nerves is almost out of the question,and the deep, descending, recurrent branch cannot have beenstruck in this case, as at the level of the wound it mustalready have broken up into its muscular branches. Again,the posterior crico-arytenold muscles cannot have beenstruck, as the hypo-pharynx was undamaged.CASE 3. Shot in the right side of the face and neck, with injury to the
vagus, the accessory, and hypoglos,çal nerves.-On August 23rd a shot froma distance of 250 metres struck the soldier on the right side of the faceand neck. He did not lose consciousness at once, but observed doublevision and interference with his speech, which became indistinct,hoarse, and weak. so that it was difficult for him to make himselfunderstood. Further, he was unable to open his mouth wide or to liftthe right arm completely. There was no bleeding from the mouth,nose, or ear, and no difficulty in breathing. A few days later the bulletwas felt further back in the neck and extracted by an incision. Fifty-five days aiter the injury he was seen by Professor Korner for the firsttime. Apart from the above-mentioned disturbances, which were stillpresent, he appeared both mentally and bodily sound. There wasfound slight paralysis of the sixth nerve and on both sides neuritis ofthe nptic nerve; the mouth could only be opened to a small extent,the teeth separating little more than 2 em. ; the tongue when pro-truded pointed to the right. The soft palate during retching andphonation was drawn strongly to the left, but the posterior wall of the
282 REVIEWS AND NOTICES OF BOOKS.
pharynx contracted equally on both sides. In the Killian position andafter depression of the tongue downwards and forwards with Czermak’suvula holder (sic) laryngoscopy could be effected; the epiglottis pointedfrom below upwards and to the left; the right vocal cord was immobilein the position of abduction ; the left one overstepped the middle lineby a few millimetres during voice production, but not sufficiently totouch the right one. The light arytenoid cartihge fell forward tosome extent; the voice was toneless and accompanied by an escape ofair, but articulation was very little impeded by the paralysis of theright hypoglossal nerve. Comparative tests for parotid secretion andtaste on both sides were undecisive owing to the closure of the mouth.In the same way it was impossible to test the sensibility of the larynx.The right sterno-mastoid and trapezius were paralysed and atrophicand gave the reaction of degeneration. The right shoulder hung downin the manner characteristic of paralysis of the accessory nerve, andthe arm could not be raised above the horizontal. The pulse duringabsolute rest was 96 in the minute. By the middle of November thecondition had not altered, except that the mouth could be openedmore widely.
Professor Korner adds : In this case it was not the larynxitself but the vagus nerve supplying it which was struck;the bullet penetrated the right zygoma, broke through theascending process of the right inferior maxilla, and lodgedin the right side of the neck under the skin where the spinalaccessory nerve comes forward beneath the middle of theposterior margin of the sterno-mastoid muscle. The zygomaseems only to have been damaged externally, and no trau-matic inflammation of the antrum supervened. Paralysisof the sixth nerve, indicated by double vision immediatelyon receipt of the wound, is out of the question. One mightsuppose that it was an injury of the abducens nerve, but thesplintering of the bone which reaches from the zygoma intothe orbits should directly involve the external rectus muscle.In regard to this the X rays gave us no enlightenment. To thiswe add bilateral optic neuritis, which at first sight may beexplained by bleeding in the skull, to which we might at thesame time attribute the sixth nerve paralysis. The closureof the mouth may be explained by the fracture of thecornoid process of the lower jaw. The vagus nerve musthave been struck high up soon after its exit from theskull, but whether it was above the giving off of thesuperior laryngeal branch cannot be decided, as the sensi-tiveness of the larynx could not be tested. This injuryled to the complete paralysis of the right vocal cordand half of the palate and to the quickening ofthe pulse. Whether the accessory nerve, injury of whichgave rise to the paralysis of the sterno-mastoid andtrapezius, was struck near its exit from the skull or onlybehind the sterno-mastoid in the neck where the bullet waslater extracted must remain undecided. Possibly theglosso-pharyngeal nerve was also damaged, but with regardto this nothing more could be ascertained on account of theclosure of the mouth preventing the necessary investigation.Finally, the hypoglossal nerve was affected. The unilateralparalysis of the tongue had the result that at first thepatient’s speech was scarcely intelligible. This difficultygradually passed away with exercise, although the hemi-plegia of the tongue and also of the larynx and palatecontinued, and are probably irreparable. Suture of theaccessory nerve might perhaps overcome the paralysis ofthe shoulder if carried out soon and one succeeded in findingthe divided nerve ends; however, we do not know wherethey should be looked for, high up near the trunk or moreperipherally behind the sterno-mastoid.The lesson drawn by the author from the three cases is
that the wounded men, although at the beginning theyshowed definite signs of injury of the larynx, were notinvestigated in the larynx either in the field hospital orlater in the hospitals far behind the scene of action; thatit was only when they reached the university town wherefor some years the official surgeons in the hospital for thereserves had been accustomed to carry out the necessaryspecial examination of their patients that laryngoscopicexamination was made; in one case 13, in another 26, andin the third 55 days after the injury; and that numerousimportant and interesting wounds of the larynx will escapeobservation and treatment, as military surgical statisticsshow, if laryngologists do not systematically search themout in the hospitals.
Another case, for which we are also indebted to Dr. DundasGrant, is taken from an article by Professor Denker (Halle),official oto-laryngological surgeon to the Fourth Army Corps,on Gunshot Injuries of the Upper Air Passages (Arch. f.0&?’.-, Ncs.-, u. Kehlkopfheilk, February, 1915). The case isof interest in itself and because it concerns an Englishofficer.
The patient was an English officer wounded in the head by a riflebullet at Etreux on August 27th. He was taken into a reserve hospitalat that place, and there tracheotomy was carried out. Then he washanded over to the reserve hospital in T. in the following condition.The patient was absolutely volceles9, wearing a tracheal cannulawhich very soon got blocked up with blood and serum. On larvngo-scopy the vocal cords were not visible, as the voice could not be pro-duced. A soft gum-elastic catheter could not be passed upwards from
the tracheotomy opening. The margins of the wound were little.irritated, and breathing through the cannula when clean was free andunrestricted. Respiration through the mouth was quite impossible.The general condition was good. The treatment at T. consisted inrenewing and cleaning the cannula. An attempt was. however, made-to close the cannula in part by means of a cork with a notch in it.The patient was sent to Halle for special treatment on Oct. 22nd.On Oct. 23rd it was found that besides the wounds in the neck thepatient had been also shot in the arm. In the region of the larynxthere was found at the height of the cricoid cartilage in the middleline and 3cm. further to the left reactionless cicatrices each of the sizeof a pfennig. Below the oricoid was the opening in the trachea in whichthere was a cannula without an inner tube. On examination of the larynxthere was seen extreme redness of the epiglottis, the margin of whichwas flexed backwards. The vocal cords were scarcely to be recognised;the right one seemed especially swollen and red. The patient wasat first treated with inhalations of M.’s salt, but in the course efthe first day he complained suddenly of difficulty in breathing. The oldcannula was then taken out and a new one with an inner tube put in its.place.On Oct. 24th under local anaesthesia of the neck and larynx, as also
of the tracheal fistula, an attempt was made to cal’ry out direct exami-nation with the help of a tracheoscopy tube. This. however, broughton severe cyanosis and dyspnoea, which made it necessary to re--
introduce the cannula. For some time little change took place in thelarynx. Respiration through the larynx with a fenestrated cannulacould only be carried out for one breath with the greatest effort andwith loud cyanotic stridor. Roentgen photography of the larynx witha soft tube (in fencer’s attitude) was taken with an exposure ofeight seconds, and it showed distinct changes in the lower partsof the larynx. When the picture taken is compared with a,
photograph of a normal larynx it can be recognised that in thelower part of the larynx and exactly in the region of the cricoidcartilage there is a difference perceptible, which shows that thecricoid cartilage at this place has been broken, up by the shot, while-in the normal larynx the arch of the cricoid can be distinctly out-lined and clearly differentiated through the bright part of theligamentum conicum from the lower margin of the thyroid;this part is completely wanting in the wounded larynx. Theplate of the cricoid appears to be preserved and marked off in,front by an irregular line. On the attempt to find a way fromthe tracheal fistula upwards into the larynx only a very fine roundedprobe could be passed. Taking together these observations along with,the Roentgen pictures it seemed clear that as the result of the woundthere was a very high degree of stenosis of the subglottic space or itmight be of the upper part of the trachea. As it semed out of the-question to make the larynx pervious by dilatation from the mouth, itwas decided to carry out a laryngo-fissure and to excise the cicatricialtissue, which had already been recognised, and then to endeavour toopen the tube of the larynx by means of Thost’s or Briigemann’s boltcannulas. Before this was carried out the growthdike thickenings,which had formed in and below the tracheal cannula and the lateralwalls of the trachea were punched away wirh a conchotome undercocaine and adrenalin anaesthesia. On Nov. 20th under scopolamineand pantopon narcosis and local infiltration anaesthesia, along withcocainisation of the larynx, the proposed operation was carried out.The incision through the skin and soft parts, beginning in the middleline above the upper margin of the thyroid cartilage, cutting down to-the cartilaginous substance, was extended to the tracheal opening. By a’puncture below the middle of the lower margin of the thyroidcartilage the subglottic space was opened and the crico-thyroid arterydivided and ligatured. From the subglottic space a bougie was passedfrom above downwards into the trachea. The soft parts lying on thebougie were then cut through with the knife. These consisted of afirm connective and cicatricial tissue in which here and there weresmall particles of cartilage. In order to keep the margins of thewound better apart the thyroid cartilage was cut in the middle linefrom below upwards for about 1 cm. with the scissors up to about the-anterior commissure of the vocal cords. The tissue was excised with aconchotome knife and scissors until a lumen of about 1 em. in diameter was produced. By probing from above it was ascertained that the wayto the larynx was quite free. Thereupon a cylindrical, firmly com-pressed tampon of iodoform gauze of the thickness of the little nngerwas inserted, and its upper part pushed up to the height of the glottis.Then the whole of the outer wound was united by stitches and a tracheal’cannula introduced. The patient complained of very little pain during-the operation. During the few following days the pain was, however,more considArable. and mucous secretion stained with blood was’coughed out in considerable quantity. On Nov. 24th the stitches wereremoved and some purulent secretion evacuated from a stitch. Afterthe removal of the iodoform gauze tampon Thost’s bolt No. 5, with thecorresponding cannula, was introduced. The patient was free from!fever, and complained only of pressure pain. Two days later thetampon and cannula were removed and were replaced by cannula andbolt No. 7. There was no discharge from the stitch. On Dec. 1st’bolt No. 8 was introduced without any great difficulty, and the opera-tion wound had completely healed. During the next few days thepatient complained only of a slight feeling of pressure in the region ofthe larynx. On Dec. 9th bolt No. 9 was introduced; the patient feltwell on the whole, and had no special discomfort in the neck.
Professor Denker comments: As regards the prognosis inthis case there seems every prospect that with sufficientlylong-continued dilatation it will be possible, to againestablish respiration through the larynx, but it is scarcely tobe expected that the vocal function can be restored. Fromthe nature of the wound it would appear that on both sidesthe lateral crico-arytenoid as well as the crico-thyroid musclehad been considerably damaged and their functions quitedestroyed. There is further a possibility that the recurrentnerve, even if not damaged, has been probably contused ordragged. It is, therefore, extremely doubtful whether a loudvoice could every be restored, though it appears, according.to observations made after complete extirpation of the vocalcords and removal of parts of the larynx, still somewhat.possible that the patient may later acquire a voice which,.though by no means normal, may yet be intelligible.
283THE STATE TREATMENT OF VENEREAL DISEASES.
LONDON: SATURDAY, AUGUST 12, 1916.
The State Treatment of VenerealDiseases.
AT the recent session of the British MedicalAssociation a recommendation was approved by theRepresentative Meeting that arrangements shouldbe made for confidential registration or certificationof the causes of death, this being one of the pro-posals of the Royal Commission on Venereal Diseases.Until such registration and certification can bemade fearlessly and candidly by medical men thepublic will not appreciate the far-spreading mischief of venereal diseases, but it is absolutelynecessary that on the one hand the feelings of thepublic should be as far as possible protected, andon the other that medical men should run no riskin discharge of their duty. The State interventionin respect of venereal diseases depends for itssuccess mainly on these two factors, whether weare considering prevention or treatment; and athird factor will be the prompt ascertain-ment of the amount of work that lies beforeus all, as gauged by the prevalence of patho-logical conditions. The Representative Meetingalso endorsed the recommendation of the RoyalCommission with regard to the keeping ofuniform records in all sickness institutions, andthis recommendation veiled an indictment of a
great many hospitals, some of them being amongour best-managed charities. If the statisticstabulated from death registers by the Registrar-General cannot be claimed as yet to afford anyclose measure of the amount of mortality fromvenereal diseases, still less, unfortunately, do hos-pital records give absolute information. If the LocalGovernment Board can devise a system for the useof hospitals and Poor-law establishments by whichaccurate statistical information can be obtainedas regards the prevalence of these diseases amongthe persons who receive institutional treatment a
great step forward will be taken. For it must beremembered that we are as yet a little in the darkas to the extent of the mischief which is nowto be combated by a thorough-going alliancebetween medicine and the public. The matteris one upon which the widest differences of
opinion have been expressed, for while one
man’s experience seems to indicate that, speakinghere of syphilis alone, the amount of diseasehas much decreased in the last generation,another, with apparently an equal right to speak,will suggest that there is a general syphilisation ofthe population. We incline to the optimistic view,which is supported by the curves of mortality from
syphilis in England and Wales for the last 30 years;but what is required, if only having regard to thecolossal sums of money that will have to be spent,is a definite knowledge, as far as possible, of theextent of the evil now. In this way when progressis made its amount and its direction can be
ascertained, so that expenditure may be open-handed in the indicated places, while being properlychecked in places where, in the absence of informa-tion, it may be embarked upon ill-advisedly.
Dr. J. A. MACDONALD, chairman of the Council ofthe British Medical Association, raised the questionwhich has, we know, occurred to many of our
readers-namely, What part the general practi-tioners of the country were going to have in dealingwith venereal diseases ? And other speakers at themeeting expressed apprehension lest the publichealth authorities should take over the whole of the
work, laying down rules which the medical pro-fession would have to carry out. If this shouldresult from the expression in law of the recommenda-tions of the Royal Commission on Venereal Diseaseswe are certain that it will be contrary to the wishesof the Commissioners as a body, and contrary alsoto the inclination of the public. Some of the Com-
missioners, we are sure, regarded it as essential forthe satisfactory working of any scheme for the pre.vention and treatment of venereal diseases thatthe local medical practitioners should be entrustedwith a full share in the organisation set up by theState to be worked out by the medical profession.The National Committee for Combating VenerealDiseases would certainly support the claims of thegeneral practitioner in this direction. Havingregard to one aspect of the matter only, a majorityof the more obscure cases will, in the first instance,come before the general practitioner. Whenthe patient himself-of course, all that followsholds good for both sexes-knows what his condi-tion is, he may be able to have recourse to anytreatment centre that he chooses, his convenienceand his privacy being consulted as far as possible-sofar, indeed, that a direct invitation to hospital abusewill be given unless methods of careful regulationare adopted. But where he is ignorant of his plighthe may consult a private practitioner, who havingdiagnosed the case, will advise as to the next
proceeding. Now in these cases, as in the caseswhere institutional treatment is sought at the onsetand where the patient is later discharged to com-plete a cure under a private practitioner, it is
necessary that the practitioner should know thewhole details of the treatment undergone at the insti-tution. It was moved at the Representative Meetingof the British Medical Association that when a
patient is discharged from an institution " it is
imperative for the continuity of treatment that areport as to his treatment during his attendance atthe institution should be kept at the institution,and that a copy should be at the disposal of anymedical practitioner who applies for it with thesanction of the patient." This is a most valuablerecommendation. If continuity of treatment isthus preserved the part played by the generalpractitioner in stamping out syphilis will be of thefirst importance, both really and in the eyes of the