1535THE SURGERY OF SPINAL CARIE&

rarer in its appearance than it has been amongst men,and we are entitled to consider that had it been presentit would have come out as it has in many members of

the male sex who have been severely handicapped bydisadvantages of nurture and education. But certain

women in former ages have enjoyed equal chances with

men. An example comes readily to mind from the

History of Medicine which tells of the mediasval ladygraduates of the Salernitan school ; but it is noteworthythat their successes did not make sufficient mark to enable

women to retain the position won for them in medi-

cine by TROTULA and her compeers. It may be con-

ceded fairly that medical women of the present dayare entering the lists on equal terms with medical men, atleast as regards education; it will be interesting to see

what proportion of medical women as compared to men50 years hence have contributed unmistakeably to the

advancement of their science. And whilst speaking on this

subject we desire to enter a protest against the commonremark that women’s equality with man will give the finalblow to the" spirit of chivalry." Surely it should foster anew chivalry, greater than the old, extended by men not tohelpmeets and sympathisers but to competitors who will

still be entitled to it because they are women. In the callingof medicine the conditions appear to us to be singularlyfavourable to the exhibition of so knightly a temper in the

professional relations of medical men to medical women.But the point which it concerns us more to examine is the

physical disability of women for executive government, anobjection to which a contemptuously curt dismissal is givenin "The Human Woman," which considers under this headthe question of maternity only. It takes no account of

the fact that every normal woman during the most

useful years of her life is subject to a recurrent physio-logical process which is always liable to become patho-logical. This being the case, it cannot be said that

women enjoy equal health with men. The assertion that

women in primitive races or in peasant classes do what weconsider men’s work is beside the mark, for we have to

consider the normal health of women of the cultured classes

of a civilised nation on whom, if on any, the responsibilitiesof government would naturally fall. We are repeatedlyassured in " The Human Woman" " that 82 per cent.

of the women of this country earn their own living. We

should be interested to know what percentage of womensuffer periodically from a physical incapability which maybe prostrating and is for a few days in every month so severeas to interfere seriously with the sufferer’s power of attentionto work. We do not deny that many women work andsuffer, but we cannot agree that such martyrdom, heroicthough it be, can ever be compatible with such efficiency asis essential to the supreme guidance of State affairs. This

argument may appear to cast a shadow upon the medical

skill of the day, but it must be remembered that no physiciancan shield his patients from the tax which their bodies payupon their heritage of civilisation. And even though it

were possible that a perfect preventive medicine should

in the future relieve women of the diseases incidental

to their sex, the supreme blessing of motherhood will

never be withheld from them whilst the race endures.

It may appear a reductio ad abszurdum to suggest the

situation of a Cabinet Minister obtaining leave of absenceat the call of maternity, but such a possibility mustbe considered resolutely before women are allowed admit-tance to Parliament. Lady GROVE would minimise theinherent sex differences of human nature. Sex forms an

infinitely wider psychical division in the human race thandoes any distinction of class when external things havebeen stripped away, and the reason is that the psychicalkinship which binds together the members of each sex is theinevitable complement of their physical kinship. It follows

that the antithesis of the two sexes must ever be the most

ineradicable fact of human nature, though Lady GROVE seeksto controvert the fact. NIETZSCHE hardly overstated thecase when he thundered forth, I It has not yet enteredinto the heart of man to conceive how foreign to each

other are the nature of man and of woman." But

there may be firm alliance between foreigners, and withcertain of the motives at the root of the struggle for

’’ women’s emancipation " many men must be in agreement.The story is as old as the human race, for in the woman’s

present protest there rings the echo of an exceeding bitter

cry from out the ages, the cry of a weaker sex in a tyrannousand degrading subjection to a stronger, and in so far aswomen’s emancipation means the wiping out of the last

traces of concubinage from the state of marriage we arein full sympathy with it ; but may this not be accomplishedby the home influence of enlightened womanhood actingthrough their menfolk ? 7 We have no space to discuss

the evolution of the present relations of the sexes into

the origins of which Lady GROVE enters in a boldlyspeculative manner, taking the view that the woman wasin the beginning "the race " and man the mere fertiliser,but begging the question of how he came to be theI super-woman" " in a piece of reasoning which we

must qualify as superficial. It is something more thandoubtful whether a substantial diminution of sexual self-

consciousness will ever come about to lift the human race to

the heights of which Lady GROVE dreams, for the desire ofthe woman will ever be to the man, and of the man to the

woman. We will leave the case to our readers with

a quotation from this clever book which we have read

with more admiration than conviction. The passage refers

to the physical strength of certain rare women, and a

Hungarian lady is mentioned who served in the Revolutionaryarmy of 1848 and who, " under the name of KARL, attainedthe rank of first lieutenant of Hussars. At this point,however, an artillery major stopped her military career bymarrying her," which we make bold to consider is the verybest thing that could have happened to her : she showed

herself a "human woman." And that, as the lawyers sa9is our case.

The Surgery of Spinal Caries.THE presidential address delivered by Dr. T. S. KIRK at

the Ulster Medical Society on Nov. 5th possessed muchinterest, for it dealt with the operative treatment of tuber-culous caries of the spine, and it must be acknowledgedthat hitherto this morbid condition has not yieldedmuch satisfaction to those surgeons who have ventured to

1536 THE SURGERY OF SPINAL CARIES.

deal with it by operative procedures. The only operationwhich has been employed to any extent for spinal caries ’

has been laminectomy and that has only been performedfor consecutive paralysis, and there is no doubt that

the general surgical opinion in this country is opposedto this operation for paraplegia following caries of the

spine. The pressure on the spinal cord which leads to

the paralysis, whether it acts directly or by the setting upof a transverse myelitis, is but little likely to be relieved byremoving the laminae of one or more vertebras. The exuda-

tion’ mass giving rise to the pressure, for it must be

very rare in spinal caries for the bone itself to exert any

pressure on the cord, is situated at the anterior part of the

spinal canal immediately behind the vertebral bodies and

to a small extent on each side. It might therefore be

reasonably expected that the mere removal of some laminse

would have no, or little, effect on the pressure exerted on

the anterior aspect of the spinal cord. The results obtained

by laminectomy support this theoretical conclusion. It is

true that occasionally the paraplegia diminishes after the

operation, but the proportion of cases in which this occursis no greater than in those where the paraplegia is treated

by prolonged rest in bed. It has therefore come to passthat most surgeons limit themselves to opening abscessesin cases of spinal caries but do not undertake any further

operative procedures.

Dr. KIRK has confined the operations which he has per-formed to caries of the dorsal and lumbar regions, for in

these the tuberculous disease is as a rule limited to the

body of the vertebra, while in the cervical region it extendsinto the pedicles and the laminag, and in the sacrum thewhole bone is usually involved sooner or later. This limi-

tation of the disease to the body in the dorsal and lumbar

regions renders the lesion more amenable to treatment andmore accessible to surgical interference. When a student

and- as a resident Dr. KIRK tells us that he saw several

laminectomies done for paraplegia from caries and later he

performed the operation once, but in all these cases the

results were unsatisfactory. In 1896 he was asked to

operate on a child who had suffered for long from com-

plete paraplegia due to caries of the dorsal spine. He

performed a costotransversectomy or MÉNARD’S operationwith very good results. He was so satisfied with the effect

of the operation in this case that he employed it in severalother similar cases and in all the paraplegia disappeared. Hewas so much impressed by the success which he had attained ’that he employed MENARD’S operation in cases of spinalcaries where no paraplegia was present but with palpablelumbar, iliac, or psoas abscesses; he evacuated the pusand removed the carious or necrotic bone. The results in 1

these cases also were favourable. Dr. KIRK then determined I

to employ the same operation in early cases of spinal caries, ’

for he was dissatisfied with the results of the usual treat-ment of such cases by prolonged rest in bed, fresh air, and 1good food, and the subsequent use of spinal supports. In ’ 1early cases the disease is limited to the body of one s

vertebra, and if this vertebral body be removed the adjacent r

bodies fall together, and Dr. KIRK finds that the deformity ’ fwhich follows is very slight. The results of those early e

operations were very satisfactory and now Dr. KiRK con- a

siders that it is the best method of treatment of early cariesof the spine in the dorsal and lumbar regions. The statistics

which he gives are not complete, for he has been unable totrace many of the cases, but the results so far as known

are as follows. In all he has operated on 61 cases of

dorsal and lumbar spinal caries. There were five deaths

immediately due to the operation. Three of these deathsoccurred in adults who had suffered from the disease for

many years. In one of these fatal cases in adults the opera-

tion was abandoned early as the anaesthetic was badly takenand the patient died a few hours later. In all the other fatal

cases the patients had large abscesses. In all of the cases

in which paraplegia was present the patient recovered fromit after the operation. In ten cases with large abscesses the

suppuration continued and eventually the patients died.

The majority of the cases left the hospital in good generalhealth, with sinuses discharging a small amount of pus, andin many of these when seen later the sinuses had healed.

In 14 cases the wounds were completely healed before thepatients left the hospital. The statistics, incomplete thoughthey are, support, in Dr. KIRK’S opinion, his plea for earlyoperation before any abscess has developed or pressure

paraplegia has occurred. It is certainly worthy of note thatnot a single case died after the operation when performed atan early stage. The rate of mortality rises with the extentof the disease, the amount of abscess formation, and the

presence of pressure effects on the cord.

The operation is as follows. A vertical incision is made

immediately to the outer side of the tips of the trans-

verse processes. If an abscess or a sinus or any indi-

cation of pressure on a nerve exists on one side the

incision is made on that side, but if no indication exists the

operation is performed on the right side. The centre of the

incision should be opposite the vertebra affected, and it mustbe borne in mind that the most prominent spinous process

belongs to the vertebra immediately above the carious body.The transverse processes of three vertebras should be exposed,and in the dorsal region an inch of the ribs external to thetubercle should be cleared and the pleura should be carefullyseparated, for it is easily perforated. The ribs are then cut

through with forceps and the transverse processes are also

divided and these portions of bone are removed. The soft

tissues are raised from the pedicles and sides of the bodies by3, periosteal elevator and the carious bone is readily found.rhe haemorrhage may be troublesome and this is best

ivoided by using the scalpel as little as possible. Three

- ransverse processes require to be removed to give free access,o the affected body. The carious bone is removed and then

)y means of a chisel or gouge the anterior and lateral walls of

he cavity must be taken away so as to allow the level

urfaces above and below to fall together and to obliterate it.he cavity is cleared out, dried, and packed with sterilised:auze soaked in a solution of picric acid. The superficialart of the wound may need to be reopened later. As soon aspossible after the operation the patient is allowed to sit up,o as to bring together the bony surfaces ; a spinal support isever employed. We have described the operation somewhat

ully so as to enable surgeons to judge of the method

mployed. It is difficult without more ample statistics. to formn exact opinion of the value of this method of treatment.

1537VEGETARIANISM & PHYSIQUE.—THE METROPOLITAN WATER-SUPPLY.

Most surgeons will not be in accord with Dr. KIRK as to the

bad results of the ordinary methods of treatment in earlycases ; in fact, in the average early case of spinal caries im-mobilisation gives excellent results, bony union taking placewithout the formation of an abscess. It is very definitely aninnovation to adopt operative procedures in early cases

and we shall watch with interest the further developmentof the method.

__________

Annotations.

VEGETARIANISM AND PHYSIQUE.

" No quid nimis."

PHYSIOLOGICAL considerations have long disposed of theview that a purely vegetarian diet ministers best to the needsof the human body, and although objection has been raisedagainst physiological reasoning on the ground that it was

largely theoretical a good deal of practical evidence hasbeen forthcoming which has justified all speculation. Itis well established, for example, that the individual who

subsists upon an exclusively vegetable diet is far more

susceptible to the attacks of disease than is the consumer

of animal food. In short, the former’s power of resistance todisease is decidedly weakened, for the reason that, after all,he is underfed, or in chemico-physiological terms, he failsto realise a sufficient intake of protein substance which

makes for bodily energy, not to mention intellectual capacity.Every day as knowledge advances and powers to add to thatknowledge are increased is the view strengthened thatvegetarianism is a fallacy. The vegetarian school has

pointed with triumph in its own mind to the oriental

peoples as examples of physical strength and endurancesupported alone by a vegetarian diet. These examples in thelight of an exceedingly interesting practical inquiry on thesubject can no longer serve the arguments of the vegetarianadvocate. We refer to a study of the problems of nutritionconnected particularly with the well-being and physique ofthe teeming natives of Bengal in relation to their diet whichconsists principally of rice. The investigation was under-taken by Captain D. McCay, I.M.S., the professor of physio-logy at the Medical College, Calcutta, and it will be

admitted, we think, that he has added a masterpieceof physiological inquiry to previous contributions. Theo-

retical considerations may be left out, although theyare obviously of interest compared with the results of

practical observations. Experimental details, also, thoughfull of scientific interest, may be omitted, but it is enough tosay that the results fully justify the conclusions arrived at.Anyone, we are told, who has seen the ordinary Bengalicoolie at work will not require much statistical evidence toconvince him of the marked superiority of the European;men have often to be employed in India for workthat women will do in England. Again, from an insurancepoint of view the life of the Bengali is very inferior tothat of the European. In spite of the fact that the Bengaliexists on a protein metabolism very close in amountto that stated by Chittenden to be sufficient, his powers ofresistance to disease are impoverished owing to an un-

replenished condition of the blood accompanying a low

protein intake. Nor is the function of the kidneys thebetter for a low protein intake, for kidney disease is morecommon among natives than among Europeans, whilst

amongst the upper middle classes the extreme presenceof glycosuria would prove conclusively " that the

danger of an excess of carbohydrate intake is even

a more real’ and present one than that of proteid excess."

From this it would appear that the human machine in healthis able to eliminate more completely the toxic productselaborated from a generous diet of protein than from

a diet overstocked with carbohydrate. At all events,in the latter case the resisting power of the tissuesto disease is decidedly lowered, so that diabetes,pneumonia, tuberculosis, spreading gangrene, and so forthare very prevalent amongst the Bengalis who subsist on a

beggarly protein diet. It follows that vegetable food, unlessconsumed in large quantities, does not yield a sufficiency ofprotein, and therefore, in order to obtain this sufficiency, aquantity of carbohydrates has to be consumed simultaneouslywhich places a strain upon the resources of the body ulti-mately leading to a reduced vitality which is favourable tomicrobial invasion and its results.

THE METROPOLITAN WATER-SUPPLY.

THE report of the Water Examiner on the condition of themetropolitan water-supply during the month of August hasbeen issued and does not call for any exceptional comment.The condition of the London water during the month appearsto have been as satisfactory as can be expected under exist-ing conditions, thanks to the absence of floods on the Thames,although the mean rainfall for August was all but an inchabove the mean average for that month. It is probable, how-ever, that this increase of rainfall will be reflected in the

bacteriological report for September. As it was, 13’ 6 percent. of 100 cubic centimetre samples of filtered Thames

water contained bacillus coli in August. This report alsocontains tables giving a summary of the state of the variouswater-supplies during the three summer months-June, July,and August. Comparing this quarter with the same months of1907 it is found that during this year the raw waters containedthe more bacteria, and in the case of raw Thames and Leawaters a larger proportion of samples contained typicalbacillus coli in one cubic centimetre of water. There were,however, slightly fewer microbes of intestinal origin in thefiltered water, which is perhaps to be accounted for by addi-tional storage before use. The report further states that"chemically, the raqv Thames water was less turbid and

discoloured, and also contained less albuminoid nitrogenand absorbed less oxygen from permanganate in the 1908summer quarter than in the 1907 quarter. The rcrnv Lea

and New River waters were slightly worse in 1908, as judgedby the foregoing tests, except as regards albuminoid nitrogenin the case of the Lea. As regards the filte’l’ed waters the1908 results compare favourably with the corresponding1907 results with the exception of the New River and

East London (Lea) districts." The further improvementof the London water-supply depends now upon increasedstorage accommodation, and it will be within our readers’knowledge that extensive works are at present beingundertaken by the Metropolitan Water Board to con-

struct a new pumping-station and reservoir at Island

Barn, West Molesey. It was high time that the Board

took advantage of the powers which were obtained bythe Lambeth Waterworks Company in 1900 but which

hitherto have been resolutely opposed by the local autho-rities on financial grounds, and this in spite of the factthat the Lambeth water has often been notably unsatis-factory. The water is to be taken from the Thames

through an open conduit taking eight feet of water

when the river is at normal level. The pumping engineswill be able to raise 25,000,000 gallons daily. Mr. C. E.

Hearson, chairman of the works and stores committee ofthe Board, in an address which he delivered recently whenMr. John Burns "turned the first sod," said that the occasionmarked th (ommencement of a series of reservoirs whichwould add a storage capacity of 4700 million gallons to the