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- who complain of cardiac symptoms on exertion but show<none of the physical signs indicative of heart disease. Thesemen, he states, are the subjects of a cardiac disability which

- is unmasked by the exertion required of a soldier. It is not a

specific variety of heart disease, and needs no such name as"soldier’s heart." In about half the cases in his seriesthe disability had been present to some extent in civil

life, and was therefore not the result of military service.’Captain PARKINSON finally expresses the opinion that theabsence of abnormal physical signs in the heart of a soldiershould not prevent his discharge from the Army if, undertraining or on active service, he shows breathlessness and ipr&aelig;cordial pain whenever he undergoes exertion well borne by his fellows. -

SURGERY.

In surgery more than in any other department of medicine- the war has overshadowed everything else. The few meetingsof the medical societies which have dealt with surgicalsubjects have had reference to the war only.

Treatment of Wounds.The foremost of the questions, discussed over and over

again, has been that of the best method of treatment of thewounds received in war, and in this war these are almost

’’

all gunshot wounds, for of wounds of the arme blanche therehave been very few indeed. The young surgeon must findhimself very bewildered as to the choice he should make for thetreatment of gunshot wounds, though it might well be thoughtthat after two and a half years of war surgeons would havecome to some sort of an agreement as to the best method toemploy. But it is not so at all. The variety of treatmentis great, and equally good results are claimed from eachtechnique. The method that is the most widely known andreceived is that introduced by Colonel Sir ALMROTH WRIGHT.He irrigates and dresses the wound with a hypertonic solutionof common salt; at first the liquid contained also somesodium citrate, but that has now been found to be un-

necessary, and its inclusion needlessly complicates the pre-paration of the solution. This hypertonic solution has severalactions, but its main function is to stimulate the effusionof lymph from the vessels of the walls of the wound. ThiseNused lymph possesses important antiseptic powers and the"lymph also contains leucocytes possessing phagocytic pro-perties. It is clear that the method has been foundedon careful laboratory experiments, and the truth of thewfoundations on which the method is based is shown by thesuccess of it in practice.Probably the next most popular application to wounds

wis a solution containing hypochlorite. One of these iseusol, and another is "Dakin’s solution." Both of thesehave been employed very largely, and of Dakin’s solutionit has been said that it possesses 30 times the anti-

septic power of carbolic acid, while at the same timeit has little harmful effect on the tissues. CARREL hasintroduced a special method of using a slightly modifiedDakin’s solution, and he claims that if the details of hismethod are followed a septic wound can be rendered sterilein about a week. A still stronger chlorine compound hasbeen introduced by DAKIN, it is called" chloramine," or"tolamine"; it is said to be five times stronger thanDAKIN’S original solution. The use of iodine in woundsseems to be completely discredited, and it appears to be nowvery little employed. Mr. A. E. MORISON introduced the use ofmagnesium sulphate and glycerine, and those who have seenits action have expressed themselves as very satisfied withthe results obtained. Captain W. B. DAVY has found muchbenefit from the use of salt tablets wrapped in gauze, packedinto the wound, and when the salt dissolves the salt acts asa drain. Major A. J. HULL has introduced the use of"salt sacs " in the treatment of gunshot wounds. Atwo-walled sac is made of bandage, between the wallsof which four layers of gauze are placed, the interior’is filled with salt, and the mouth of the sac is sewed

up. One or more of these sacs are used to fill thewound, any spaces between being occupied with gauze.The drainage is said to be perfect, every portion of thewound being drained by the osmotic action of the salt.The dressing does not, as a rule, need changing for a weekor so, and the results are said to be excellent.

Dr. LOUISA GARRETT ANDERSON, Dr. HELEN CHAMBERS,and Miss LACEY have conducted at the Endell-street Mili-tary Hospital an investigation into the relative value of

, various methods of dealing with septic wounds, and amongstother results they have found that a solution of salicylic

L acid, about two drachms of a saturated alcoholic solution to. a pint of water, forms a very effective lotion to a septic: wound, for the crystals of the salicylic acid become

deposited in all parts of the wound, and a diminution in. the number of bacteria on the surface of the wound occurs.They have also found a mixture of salicylic acid and

: gelatin very useful; the mixture, with the gelatin liquefiedby heat, is poured into the wound and fills the recesses

accurately. Major T. F. BROWN has obtained very satis-

factory results with picric acid ; it is known to be a veryefficient antiseptic, and as it also possesses marked anodyneproperties, and as it stimulates the growth of granulation,its employment is likely to be extensively useful ; the mainargument against it appears to be that at the present timepicric acid is being so widely employed ,in the inflictionof wounds that the Munitions Department might raise

objections to its employment in their cure. MajorGEORGE STOKER has experimented with the applicationof ozone in the treatment of septic wounds, and hehas found it very useful. At first there is an increasein the amount of pus formed, but it soon diminishes inamount, and before long the discharge becomes serous incharacter.

It will have been seen that there is a very large number ofapplications from which the surgeon can choose; we haveno doubt that good results can be obtained from any ofthem and from many other dressings which we have notmentioned, but in practice the exigencies of time and spacego far to limit the number of methods which are reallyavailable.

Captain R. H. JOCELYN SWAN and Mr. KENNETH GOADBYhave met with no small measure of success in the treatmentof septic wounds by means of vaccines, and, in fact, CaptainSWAN now makes it a rule that every case arriving fromoverseas with a septic wound shall, on entrance into thehospital, have an initial dose of a mixed polyvalent vaccineof proteus and streptococcus. He is satisfied that thistreatment has to a large extent assisted the other methods oftreatment employed. It tends especially to prevent secondaryhaemorrhage. In order to control the results he had otherwards in which no vaccines were employed, and it was inthose cases not treated with vaccine that secondary h&aelig;mor-rhage occurred. He points out that it is unreasonable to

expect that a vaccine should cure a septic wound if unaidedby the ordinary surgical measures such as drainage.

Head Injuries.The proportion of head injuries is not so great now as it was

at an earlier stage of the war, and this is, in part at all events,due to the fact that the steel helmets have gone far to reducethe number of cases. A bullet travelling at high speed caneasily penetrate the helmet, but it arrests low-speed bullets,and it is specially useful in stopping shell fragments. MajorALEXANDER DON has described his experience with headcases at a casualty clearing station, and he comes to theopinion that the linear or angled scalp incision, as practisedby most French surgeons, with a small trephine opening, ismore useful than the large scalp flap as practised for themost part by the British surgeons, for the results, as he hasseen them, are better. Captain H. F. WOOLFENDEN hasdescribed two cases in which during the operation for theremoval of a foreign body from the brain he opened thelateral ventricle, and yet the patients recovered, the sepsispresent being but slight.

Captain H. ELWIN HARRIS has reported an interestingcase in a man who, while being dressed for a wound in thehip, was struck by another bullet which made him uncon-scious. No bullet wound was found, but from a considera-tion of the circumstances and the examination of theskiagram, it is clear that the bullet entered at the left innercanthus, passed between the eyeball and the inner wall ofthe orbit, and that it then entered the sphenoidal sinus,after wounding the optic and the third nerve. By the expen-diture of a large amount of trouble Captain HARRIS atlength succeeded in withdrawing the bullet through the leftnostril. The patient recovered rapidly.

Sir WILLIAM J. COLLINS has described a case in which veryextensive destruction of the right side of the face from theear to the nose had occurred. Seven operations were per-formed before the patient came to England, and two furtherplastic operations were performed ; and then an artificial

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cheek was designed of painted and moulded copper-platewith an eye attached and carrying a pair of spectacles, witha very satisfactory cosmetic result, as shown by a photographpublished in these columns.

Some Curious Cases of Shot Wound.Many remarkable cases showing the result of treatment of

shot wound have been recorded in medical literature, andspace only allows us to refer to two examples.A gunshot wound of the inferior vena cava is almost

certainly fatal, but Captain D. C. TAYLOR has recorded a casein which a fragment of a bomb entered above and to the right of the umbilicus. When the abdomen was opened, Itwo large tears in the jejunum were found ; both of thesewere sutured, and then a retroperitoneal haematoma wasseen, and when the posterior peritoneum was slit up withscissors there was furious bleeding from a longitudinal tearin the vena cava three-quarters of an inch long. The holein the vein was closed by means of six pa’rs of arteryforceps which were left on and were not removed until thefourth day. The patient recovered.

Mr. L. E. BARRINGTON-WARD was able to remove a bulletwhich had made its way into the middle mediastinum. Theman had been wounded, and about five months later he

rejoined his regiment for further service, but he had pains inthe chest with shortness of breath on marching. The

skiagram showed a bullet apparently lying in the peri-cardium. At the operation the pericardium was openedanteriorly and the bullet was looked for but not found. The

lung and pleura were gently separated from the pericardiumand then at a depth of 4 inches the bullet was found, with afew drops of pus. The bullet was removed and the patienthad an uneventful recovery.

Celluloid in Plastic Surgery.In much of the plastic surgery needed in the treatment of

extensive injuries the surgeon often finds great difficulty infilling up spaces where the tissues have been extensively lost.Mr. C. HIGGENS has used celluloid plates with very goodeffect, though great care had to be taken that the piece ofcelluloid did not press upon the line of the suture, or it wasliable to prevent healing. Later, however, he found that asolution of celluloid was even more useful ; it is injectedgently with a syringe having a screw piston. These injec-tions have done so well that he has given up the use of theplates.-

Left-sided Appendieitis.It is well known that the pain of an appendicitis may be

felt not in the right iliac fossa but on the left side of the

body, and whatever the explanation of this may be, theappendix is situated on the right side. There is, however, amuch rarer condition, in which by a transposition of viscerathe caecum, is on the left side of the body, and whenin such a case an appendicitis occurs, the signs and

symptoms may be found on either side. Dr. GRAHAM W.CHRISTIE has described a case in which there was a left-sided appendicitis, though the pain was on the right side ;but in another case under Dr. C. E. CORLHTTE, when theabdomen had been opened, no c&aelig;cum could be found on theright side, and on further examination it was discovered thatthere was an absence of the transverse colon, and theascending colon was in contact with the descending colon.Such cases as these are very disconcerting when encounteredat an operation.

Abdominal Operations on Children.As a rule very small children do not stand abdominal

operations well, especially those which are in any way pro-longed. Surgeon C. P. G. WAKELEY has put on record avery striking case in which the stomach of an infant onlysix months old was opened to remove a brooch whichhad been swallowed two days before. By means ofa skiagram it was seen that the brooch was in thelower third of the cesophagus, with the pin pointingtowards the mouth. An attempt was made to close thebrooch by the use of the bronchoscope, but the only resultwas to push the brooch into the stomach, from which it wasremoved through an abdominal incision. The pin of thebrooch had passed through the anterior wall of the stomach,and so a slight and local peritonitis had arisen. The woundhealed well and the child recovered completely. Dr. IDA M.GUILLAUME has related the particulars of a case in which achild only 15 days old had had a strangulated hernia for

four days, when Captain J. W. WALKER operated, althoughthe child appeared almost moribund. A strangulated leftinguinal hernia was found and released. Gangrene of thetest.is had occurred from pressure, but complete recoveryfollowed.

Dr. F. M NEILD operated on a boy 10 years old for perfora-tion of the bowel from typhoid ulceration about eight hoursafter perforation had taken place. The child did well fornine days after the operation ; then acute intestinal obstruc-tion took place, and when the old wound was reopened itwas seen that the obstruction was due to pressure from aband of omentum. The obstruction was removed and thepatient recovered. Mr. W. H. BATTLE has pointed out howdifficult it is sometimes to recognise a rupture of thebowel, for the signs and symptoms may be extremely obscure,so that unless the surgeon is waiting for the symptoms tomanifest themselves the opportunity to operate may pass by.He expresses his agreement with the teaching of the lateMr. BERNARD PITTS that exploration should always be donewhen there is a clear history of an abdominal injury, suchas a kick from a horse.

Removal of b’oreign Bodies from &OElig;sophagus and Brone7ti.The removal of foreign bodies from the oesophagus and

bronchi has been much facilitated by the introduction of thedirect method, and Mr. IRWIN MOORE has described anumber of instruments and processes aiding their removal ;especially he has devised some non-slipping forceps of proved

utility. H has also designed endoscopic shears, which can cutthrough tooth-plates

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OBSTETRICS AND GYN&AElig;COLOGY.

Twilight Sleep.A subject which has excited a good deal of interest of

late, more especially in the lay press, is that of anaastbesiaduring delivery, and particularly that variety of it called"twilight sleep." The subject was considered in a leadingarticle in THE LANCET of Sept. 30th. This is a variety ofmorphine-scopolamine narcosis, and was strongly recom-mended by GAUSS in 1906 when he published his experiencesof it in 600 cases. The steady fall in the birth-rate is

beginning to cause general alarm, and it has been suggestedif women could be assured that the pains of childbirth couldbe relieved to a marked degree that they would be less reluc-tant to bear children. Since its original introduction themethod has been tried in a large number of clinics in thiscountry, on the continent, and in the United States. On thewhole, it has not met with complete approval. The chief objec-tion raised to its use is its alleged tendency to produce frequentasphyxia and death of the child, and prolonged labour withthe danger of post-partum haemorrhage on the part of themother. Many obstetricians, too, have been disappointedwith the results as regards the amnesia it is designed toproduce. The method depends for its action on the factthat scopolamine tends to cause loss of memory. Thewoman perceives the pains at the time to a greater or lessdegree but completely forgets them, and on waking up halfan hour or so after the birth of the child is totally obliviousof the fact that she has had any pains. If success isdesired it is necessary to observe very carefully the

special technique laid down by the introducers. The first

injection must be given when the pains are recurringevery three to five minutes and are lasting, as measuredby the watch, from 30 to 45 seconds. If the injectionis given before this stage is reached it will be too soonand uterine inertia is likely to supervene, and if it is

given after this stage it is very difficult to secure thedesired degree of amnesia. The second dose, of scopolamineonly, should be given three-quarters of an hour after the firstinjection of scopolamine and morphia. The morphia in anordinary case should not be repeated. Half an hour afterthe second dose has been administered the patient’s memoryshould be tested, and a third dose, if necessary, given one toone and a half hours after the second dose. It is notadvisable to give more than four doses of scopolamine,although in exceptional cases it may be necessary. Theuterine contractions, the maternal and foetal heart sounds,must be carefully watched, and the patient should beunder the constant supervision of a medical man andshould not be left to the care of a nurse. The dose

given must be carefully determined by the memory test