25

ten days of his illness; afterwards Dover’s powders and adiet of goat’s milk. He had had no nausea, vomiting,cough, or symptoms referable to the chest or abdomen ; thestools, two or three per diem, had been ’’ porridgy " ; therewas no blood, mucus, or pain with movements of the bowels.His previous history elicited an eight months’ residence inthis country during which he had had many attacks of

"fever" ; one attack had been thought to be tick fever ; inthe last attack, however, malarial parasites had been found.Previous to coming to this country he had been inSouth Africa for nine or ten years, and in 1901 had beentreated in Bloemfontein Hospital for enteric fever, followedone week after discharge by dysentery with typical acutesymptoms, the attack lasting four weeks. Since then, tillthe present illness, he had had no returns of symptoms ordiarrhcea.On the evening of admission the blood was examined for

malarial parasites and two only were seen, ring forms

(malignant tertian), no crescents. The following five daysquinine was given: 15 grains the first two days and then 20grains as solution of bi-hydrochlorate. This had no effecton the temperature, which showed an evening rise, averaging101°, and the pulse was from 66 to 88 per minute. The

The complete chart also recorded a pulse frequency varyingfrom 66 to 90, generally keeping between 80 and 88. Therecord of the evacuations showed " loose" on the secondday, "3 loose "on the third day, then " loose" with oneintermission until the twelfth day, after which 1 formed" is recorded daily with two intermissions. The diet isalso described. " Nov. 13th: Milk, soda, chicken broth.Nov. 26th: Milk pudding, bread and butter. Nov. 28th:Eggs, toast, fish, potato. Dec. 1st: Chicken, duck."

urine was normal. There were two motions per diem,watery, with little faecal matter, but neither mucus nor bloodexcept on the second day after admission when what

appeared to be a small old blod clot was passed. No

improvement was effected by 20-grain doses of bismuththree times a day for three days. Microscopical examina-tion of the stools proved negative as regards amosbae. The

tongue was thickly furred and the patient complainedof weakness, headache, and profuse sweats in the evening.The spleen could just be felt; the liver showed no enlarge-ment to percussion or tenderness to palpation ; there were noother physical signs in the chest or abdomen. At the end ofthe week, during which time no other malarial parasites hadbeen found, quinine was discontinued and it was determinedto try ipecacuanha. It was given in wafer, in 20-grain doses,on two consecutive days on an empty stomach, 20 minutesafter a 20-minim dose of tincture of opium, as recommendedby Manson. The result was immediate : the temperaturecommenced to fall, reaching normal in four days, and there-after not rising again; the stools became more and moreformed, being normal in three days ; the tongue cleaned, andthe patient expressed himself as feeling much better. Theconvalescence was uneventful, full diet being attained by theend of a week of normal temperature.Major Rogers lays stress on a particular type of leuco-

cytosis as being of value in making a diagnosis in these

cases. Unfortunately, I was unable to make a ’’ white count " till after the treatment had done its work-whitecells then numbered 9000 per cubic millimetre. I think, how-ever, that with the past history of dysentery the three weeks’pyrexia, immediately reacting to treatment by ipecacuanha,places this case among those that Major Rogers puts inClass IV. of his series, "Cases without Dysentery or LiverSymptoms treated with Ipecacuanha." Blantyre, Nyasaland.

A NOTE ON THE EXTRACTION OF FOREIGNBODIES FROM THE TISSUES.

BY HUBERT CHITTY, M.S. LOND., F.R.C.S. ENG.,RESIDENT CASUALTY HOUSE SURGEON, ST. MARY’S HOSPITAL,

PADDINGTON.

THE following description applies only to the removal ofthose bodies which are opaque to the x rays. The patient istaken into the x ray room and the foreign body is roughlylocalised with the aid of a fluorescent screen. The area inwhich an incision will have to be made is then carefullycleansed and is infiltrated with a 1 per cent. solution ofeucaine. A further examination of the part is now madewith the x rays. Guided by the shadows thrown upon thescreen, the surgeon plunges the needle of the infiltratingsyringe into the tissues till it touches and (in the case of aneedle) lies as nearly as possible parallel to the foreign body.A few more drops of solution may now be injected and thesyringe is then detached from its needle, which is left

sticking into the part. This needle is cut down upon andthe incision necessarily exposes the foreign body at the sametime.

Except where the foreign body lies very deeply it is often

quicker to surround both it and the localising needle by anelliptical incision and to remove them both, together with alittle skin and subjacent tissue, in one mass. The woundwhen closed by a stitch or two leaves no more scarring thandoes a linear incision.

I have chiefly used this method in cases of ’’ needle in thehand," but it is, of course, equally applicable to the removalof glass, shot, &c. It is rapid and certain, and the minimumof damage is inflicted on the soft parts. Strict asepsis iseasily maintained, for, once the infiltrating needle has beenbrought into contact with the foreign body, no further screen-ing of the part is required.

This plan for localising a foreign body is simpler and moreaccurate than any method of skin marking with which I amacquainted. Anyone who has had to hunt for small pieces ofneedle deeply imbedded in the muscles will appreciate its

advantages.St. Mary’s Hospital, Paddington.

Medical Societies.ROYAL SOCIETY OF MEDICINE.

MEDICAL SECTION.

The Tone of Cardiac Muscle.A MEETING of this section,was held on June 23rd,

Dr. D. B. LEES being in the chair.Dr. A. M. GossAGE read a paper on the Tone of Cardiac

Muscle. He said that muscle was probably capable of twokinds of contraction-the ordinary twitch and "tone, andthese might occur separately or in combination. Tone wasnever absent, so that the ordinary muscular contraction wassuperimposed on tone, but increase of tone diminished thesize of that contraction; in other words, tone diminishedcontractility. Tone, unlike the ordinary muscle twitch, hadno refractory period and was directly dependent on thestrength of the stimulus. Tetanus was purely a phenomenonof tone. In cardiac muscle Porter had shown that tonediminished conductivity as well as contractility andit was probable that it also diminished excitability.Dilatation of the heart was due to loss of musculartone and, as would be expected, was associated with

increase of excitability, conductivity, and contractility.

26

Indeed, the tone of cardiac muscle might be regarded as amethod of storing up a reserve of force which was liberatedon dilatation of the heart. The action of the cardiac tonicswas mainly to cause an increase of muscular tone. In con-

sidering human hearts it was found that the phenomena ofdilatation of the heart conformed with the theory as to theinfluence of tone. In the dilated heart the diastolic relaxa-tion was obviously greater than in the normal heart, or, inother words, tone was diminished. In association with that

they found excitability increased, as shown by the increasedrate and the frequency with which extra systoles occurred.Conductivity was probably also increased, since they foundno lengthening of the interval between the time of con-traction of the auricles and that of the ventricles, althoughthe heart was beating more rapidly. Experiments on

animals showed that the recovery of conductivity was agradual process requiring a certain amount of time and itwas probable that the same was true of human beings,especially as a very considerable time was required for therecovery of conductivity in cases where it was depressed.In the dilated heart contractility was also increased,since the heart had to perform more work to main-tain the circulation, and in the majority of cases thecirculation was in a fashion maintained. The intense labour

performed by the heart, even when ineffectual, was a commonclinical experience in cases of dilatation. This excessive

expenditure of energy was always liable to be followed byexhaustion and then the heart would fail in its task of keep-ing the circulation up to a sufficient standard. Since thedilated, toneless heart had to work too hard and was alwaysin danger of failing, their object in treatment must obviouslybe to restore some of the lost tone. It was, of course,possible that that could be done by mechanical means ; withdiminished work there might be diminished pressure withinthe cardiac chambers and that might help in the restorationof tone. At any rate, the beneficial effects of rest and

bleeding in cases of dilatation of the heart had long beenrecognised. Mechanical measures were, however, ofteninsufficient and had to be supplemented by the use of drugs.Unfortunately, the action of drugs was seldom a simpleaffair and the results of experiments on animals were notalways borne out in the clinical treatment of patients. The

drugs employed in the treatment of dilatation and heart failurebelonged mainly to the digitalis group and it was of greatimportance to understand their exact mode of action. Digi-talis and strophanthus had in animal experiments a verysimilar action, except that digitalis constricted the vesselswhile strophanrhus did not, and thus digitalis had the greatereffect of the two in raising the blood pressure. Amongother vessels, however, it also constricted the coronaryarteries, and the flow of blood through the coronaries wasof immense importance to the heart, increase of flow leadingto increased size of the contraction and vice versii. Evenincreased tension in the coronaries with an indifferent fluid,such as oil, might cause a quiescent heart to start beatingagain. Cushny pointed out that digitalis had two opposingactions on the heart-(1) as a stimulus and (2) as a bridle-and that it was difficult to predict which result would followits exhibition in a particular case. It seemed possible thata very large part of the action of digitalis might be explainedby regarding it as a powerful stimulus to the heart, verysimilar to the interrupted electric current in Porter’s experi-ments. It would stimulate the vagus, the muscle directly,and tone. In the hearts of animals the first effectof digitalis was usually increase the size of theindividual contractions, and at that stage the diastolicrelaxation was often more marked, or, in other words,there was some diminution of tone. Together withthose phenomena the rate of the heart was sometimesincreased. Later there was a decided and gradual increaseof tone, usually a diminution of rate and gradual decrease insize of the contraction. Still later the rate increased againwith a further increase in tone ; then delirium cordis mightsupervene and the heart finally stopped in a condition ofexcessive tone. The resemblance of all that to the phenomenaaccompanying gradually increasing tone in Porter’s researcheson the auricle of the tortoise was very striking, the maindifference being that with digitalis the whole process tothe stoppage of the heart in excessive tone or tetanustook much longer. Closer investigation had shown thatexcitability to direct stimulation was decreased in digitalispoisoning, while conductivity was also diminished even some-times to the extent of causing a block between auricle and

ventricle. Since Porter had demonstrated that increase oftone was sufficient to produce decrease of contractility (asshown by the diminished size of the beats) and decrease ofconductivity, the action of digitalis in lessening those twoproperties must be partly due to its effect in augmenting themuscle tone and might be entirely due to the alteration oftone. The diminution of excitability was probably alsopartly due to the same cause, an increase of tone. Lossof tone was certainly associated with increased excitabilityso that it was probable that increase of tone would lead todecrease of excitability. The increased rate which appearedlater in digitalis poisoning was probably due to direct,stimulation of the muscle by the digitalis, while the terminaldelirium cordis would have the same causation as the similar

phenomenon noted by Porter with increased tone, theventricle not contracting as a whole, but isolated portions ofthe wall contracting separately owing to decrease of con-

ductivity. Indeed, Sowton noticed that samples of digitalisthat caused marked delirium cordis usually also brought,about a striking decrease of conductivity as shown by thenumber of the auricular beats that were not conducted to theventricle. In that connexion it was interesting to note thatMuskens had offered a similar explanation for the occurrenceof alternating action of the heart in digitalis poisoning.That action where the beats were alternately large and small,.although the intervals between them were approximatelyequal, had usually been attributed to failure of contractilitybut Muskens regarded it as resulting from a depression ofconductivity which led to isolation of portions of theventricular wall, and after every normal beat a contractionof only part of the ventricle. From animal experiments,then, it seemed that digitalis acted at first as a stimulusto the heart, increasing the contractility and often the rate,possibly also conductivity and excitability. Later it stimu-lated tone and with increased tone there was diminution of

contractility, excitability, and conductivity. In human,

beings the amount of the drug that reached the heart mustbe small and the amount that it was possible to administerwas limited by the irritant effect of digitalis on the gastro-intestinal tract. It was to be remembered, however, thatthe drug was cumulative in its action so that a considerableeffect might be produced by small doses continued over along time. The irritant action on stomach and intestinewas not observed with strophanthus and that possibly con-stituted one of its dangers. The early stage of stimulation.was difficult to demonstrate in clinical work, although it.

might be of importance. Practically, however, as Mackenzie-had recently pointed out, it was only in cases of dilatation,that marked results were obtained, or in other words that,digitalis acted therapeutically mainly on the function oftonicity. Improvement often occurred quite suddenlyalthough the drug might have to be administered for severaldays before any effect was produced. Very rapidly there;

might be a sensible decrease in the dilatation, the oedema.might diminish, the liver shrink in size and there might be &’

decided rise in the blood pressure and in the amount of urine-secreted. Coincident with’the decrease in the dilatation therhythm became less frequent and any irregularity was’lessened. The decrease in frequency and irregularity was,.no doubt, partly due to diminution of the excitability,.though direct stimulation of the vagus might be the cause-of a decreased rate of stimulus production and so a ’less-frequent rhythm. Mackenzie had shown that a normal’heart, or a diseased heart which was not at the same time-dilated, was practically unaffected by such doses of digitalisas could be given to men by the mouth. That was perhaps:only what should be expected since it was probable that asmaller dose would be required to increase the tone of adilated heart (i.e., where tone was much diminished) than to’add to the tone of a heart where it was already at the-normal standard. The excitability of tone varied withdifferent circumstances in animals and no doubt had the-same variability in human beings. It was in cases of recentdilatation, or recent increase of dilatation when the musclewas healthy that the tone of the human heart seemed espe-cially susceptible to the influence of digitalis. Experi-mentally tone diminished contractility and conductivity andnot improbably excitability also, so that they would expectdigitalis when it increased tone in men to decreasethose other properties. Its - effect on excitability was

apparent ; the diminution of rate and of irregularityshowed its restraining influence. There were, however,instances where a heart which was originally regular-

27

became irregular under the administration of digitalis.That irregularity was of several kinds, of which thecommonest form was the development of a "bigeminalaction" where an extra-systole followed each normal beat.A bigeminal action was not uncommon in over-excitablehearts where no drug had been employed, and a probableexplanation of its occurrence after digitalis was that the.decreased rate had allowed a hidden bigeminal action to.appear. For that explanation to be applicable it was

necessary that the interval before the extra-systole should!be longer than the intervals between adjacent beats beforethe administration of digitalis. Hering showed that a

bigeminal action might be made to disappear by giving.atropine, its disappearance coinciding with the time when-the normal rhythm became so rapid that a normal beatoccurred exactly at the moment when the extra-systole

- ’would be expected: any rate faster than that was

regular, while any slower rate, as shown when the,effect of the atropine wore off, was of the bigeminal,character. A bigeminal action was not necessarily.constant and they would not always expect a constant bi-geminal action in cases occurring after digitalis. It wasnot necessary, therefore, to assume that in these cases the.digitalis caused an increase of excitability contrary to itsusual action of decreasing excitability. A second type of

irregularity after digitalis might be produced by the occur-rence of isolated extra-systoles. That might, of course, bemerely a consequence of reduction of rate, since with arapid rhythm there was very little opportunity for the occur-rence of extra-systoles. Another type of irregularity after-digitalis had to do with the depression of quite a differentproperty of the muscle-namely, conductivity. There was-abundance of evidence that digitalis depressed conductivityin animals and Mackenzie had shown that the same actiontook place in human beings provided that conductivity was-somewhat depressed before the drug was given. In somecases there might be an apparent improvement in con-

ductivity after digitalis owing to the slower rate giving moretime for its recovery. In view of the small doses that itwas possible to administer it is not surprising that depressionof conductivity by digitalis was only observed clinically incases where there was already evidence of its being damaged.The effect of digitalis on contractility was more difficult toestimate. There was no doubt of the more efficient working- of the heart when digitalis had been given in suitable

cases. That was partly due to the mechanical advantage ofthe decreased dilatation brought about by increased tone andpartly due to the fact that the slower rate allows a longer-time for the contractility to recover. In animal experiments,’however, it was clear that both an increase of tone and the.administration of digitalis resulted in a diminution of contrac-tility. That drug, too, often produced an alternating action ofthe heart which had been supposed to be the expression of,damaged contractility. The evidence of depression of con-tractility by digitalis in the human heart seemed sufficiently’clear and they could have no doubt of that action of digitalisfrom the results of animal experiments. Probably only-those patients whose contractility was already depressedwould show any further recognisable lowering with digitalis.’The foregoing arguments afforded sufficient justification for;affirming that tone played the same important role in the’human heart as in the animal and that increase of toneihad the effect of diminishing the other properties of the,cardiac muscle-namely, contractility, excitability, and

’conductivity. That conclusion, too, was of considerableclinical importance. The recognition of loss of tone as

the important factor in dilatation of the heart was a

-great advance, and they now found in addition that

many of the phenomena associated with dilatation were

<directly due to that loss of tone. The dependence of the"other properties on tone afforded a remarkable method of’self-regulation in the heart, so that it was enabled to do justthe amount of work which was required of it. Some light was.also thrown on the obscure subject of the action of digitalis on the heart, though it could not be said that that questionwas completely answered. Part of the action of digitalis was evidently secondary to its influence on the muscle tone, but how much of the damage done to contractility, con- J

ductivity, and excitability came from increased tone and (

how much from stimulation of the vagus could not at l

present be estimated. The narrowing of the coronary I’vessels would probably also tend to depress the properties t

of the cardiac muscle to an extent that was incapable ofexact appreciation. It was important to note that inthe case cited the digitalis had greatly improved the

patient’s general condition as well as the general working ofthe circulation in spite of the grave depression of con-

ductivity and the occasional dropping out of ventricularbeats. Mackenzie’s and Gibson’s patients had also bene-fited from the drug, although contractility was so damagedthat there was alternating action of the heart. Evidentlythe improvement resulted from the increase of tone and thesefacts received their simplest explanation in the conception oftone that he (Dr. Gossage) had advanced.

’

Dr. J. MACKENZIE said that the paper had helped him tounderstand why there was an increase in the rate of theheart’s beat in cases where sudden dilatation had taken

place.Professor A. R. CUSHNY said that it was interesting to find

Dr. Gossage going back to the view that the action of digitalison the heart may be due to what was called its elasticity,which was very much the same thing as the tonicity describedby Dr. Gossage.

Dr. A. MORISON said that in the discussion of the subjectthey could not eliminate the influence of the nervous systemor that of the blood.

Dr. H. A. CALEY said that the value of the paper by Dr.Gossage consisted in the evidence which it contained that

digitalis was indicated in cases of cardiac myasthenia withdilatation, and if digitalis failed to do good in suchcircumstances causes such as degeneration of the coronaryarteries or actual degenerative changes in the myocardiumitself must be considered.

Dr. LEES laid stress upon the importance of ascer-

taining the true size of the heart in cardiac conditionswhich he said could quite easily be done by careful percus-sion. The use of digitalis was not indicated in cases oflilated heart due to an acute toxic condition, but where the;ondition was chronic then digitalis was useful.Dr. GOSSAGE replied and the meeting terminated.

SOCIETY OF TROPICAL MEDICINE ANDHYGIENE.

Afracccn Tick Fever.A MEETING of this society was held on June 19th, Sir

PATRICK MANSON, the President, being in the chair.Dr. C. F. HARFORD read a paper on African Tick Fever

with special reference to its clinical manifestation and itsrelation to relapsing fever of India and other parts of theworld. He said that the question must be raised as to howfar tick fever had existed, for instance, in such a territory asUganda for many years past, and whether the increase wasas rapid as it seemed, or whether the increase was chieflyapparent and was really due to the fact that it was not

recognised before. One point was quite clear and that wasthat the systematic examination of the blood, which was nowbeing carried out by many medical men in Africa, made itpossible to diagnose many diseases with certainty in a waywhich was not possible before. The society had consideredon various occasions the special characters of spiro-ch&aelig;ta Duttoni which was generally acknowledged to bethe cause of African tick fever, and he would only ventureto express his opinion that the organism belonged to the

protozoa, and that whilst there, no doubt, were slight morpho-logical differences between that parasite and the one usuallyknown as spirochasta Obermeieri, yet those did not appearto be greater than, if as great as, the differences betweenvarious forms of malarial parasites. He took it as provedthat the form of fever, which for the sake of convenience hereferred to as tick fever, was conveyed by the tick ornitho-dorus moubata. He then considered the series of notes of 66cases which had been most kindly supplied to him by Dr. A. R.Cook and Dr. J. H. Cook of the Church Missionary Society,Uganda. Of the 66 cases 39 were males and 27 females ; andagain, out of the total number 46 were adults and 20 werechildren. Of the total number 57 were cured and nine werefatal. Blood examination was recorded in 57 out of the 66cases and spiroch&aelig;t&aelig; were found in all of these except one.In one of the cases only one spirochseta was found after aprolonged search, but in others they appeared to have

been fairly plentiful. In some cases where spirochaetaa