903

hurry he neglectei to retard the spark, and taking a tighthold of the handle he gave it a sudden pull, when, instead ofstarting, the engine fired back and he received a violentshock on the hypothenar eminence. As an interested crowdwas now collecting the injury was not taken much notice ofand the driver, retarding the spark, quickly restarted theengine and proceeded on his way.When I first saw him, which, as already stated, was ten

days after the accident, there was a prominent swelling overthe proximal half of the fifth metacarpal bone of the righthand, and on manipulating the bone I expressed the opinionthat it was fractured. In order to decide the diagnosis, Inext day sent the patient to have a skiagram taken andthe fifth metacarpal bone was seen to be fractured at thepoint of junction of its base and shaft. The picture was notso clear as it would have been had the hand been radio-

graphed immediately after the accident as there was a largeamount of temporary and partially impervious callus showing.The patient made an uneventful recovery.

Several cases of fracture of the lower end of the radiushave been recorded as the result of firing back of motor-carengines when attempts have been made to start them whilstthe spark was advanced but I have seen no case recorded inwhich a fracture of any other bone occurred during this

manipulation. The fact that in this case it was the fifth

metacarpal bone which gave way is sufficiently accountedfor when the conditions under which the accident occurredand the various factors at work are considered. First, Iin the hurry, a tight and strong grip was taken otthe starting lever, the driver’s hand being passed so farround the handle that its olivary end rested on the hypo-thenar eminence; and secondly, the spark was so faradvanced that any back-fire occurring was sure to be a sharpone and such as would allow no time for the release of thehandle. The quick recoil was therefore transmitted mostforcibly through the most prominent part of the handle-namely, its olivary end-which was resting directly over theportion of bone fractured. Had a less tight grip of thehandle been taken the principal effort required to start theengine would have been exerted by the thumb and indexfinger and therefore when the back-fire occurred one of twothings might have happened-viz., either the hand:e wouldhave flown from the grasp altogether or the force wou’d havebeen transmitted through the first and second metacarpalbones to the lower end of the radius, resulting in a fractureof that bone.Sunderland.

NOTE ON A CASE OF TETANUS AFTER THE IN-DUCTION OF PREMATURE LABOUR.

BY W. HERBERT GREGORY, M.D., C.M. EDIN.

THE patient in the present case was a multipara, 42 year,of age ; she had had nine pregnancies and one miscarriageand she missed a period on Sept. 29ch, 1905 Haemorrhage,sometimes slight, sometimes amounting to flooding, came onin the middle of November and continued for ten weeks. I

made examinations on several of these occasions but couldnever find anything abnormal. Complete rest in bed wasordered and small doses of opium were given. On Jan. 26 h1906, a serious haemorrhage occurred ; the os uteri was foundto be undergoing dilatation and a miscarriage was evidentlythreatening. With the assistance of Dr. George Savege,who kindly gave chloroform for me, I dilated the os digitallyand removed a four months foetus. There were no troublewith the placenta and no post-partum hemorrhage. Al)went well for six days, the temperature being normal andthe pulse-rate never above 80. The discharge also bar)

practically stopped at the end of that time. On the eveningof Feb. lst the patient complained of stiffness of thl-’muscles of the neck. I saw her on the next morning andfound her head retracted and the jaws tightly closed.There was typical risus sardonicus and she spoke with greatdifficulty. I had her at once removed to the Cottage Hospital here so as to have her under close observation. Tonic

spasms involving the muscles of the trunk and limbs cameon in the afternoon and in the paroxysms a condition ofpleurosthotonos was present. Feeding had to be carriEdon by the bowel as any effort to feed by the nose cr roundthe teeth by a tube brorght on a paroxysm. There wasmuch pain during the spasms, especially in the region of

the neck, also great lividity of the face and neck, profuseperspiration, and rapid breathing. The patient was quiteconscious during the spasms, which increased in numberand intensity on Feb. 3rd, there being from 25 to 30 on thatday. Her temperature continued normal throughout, buther pulse was feeble and irregular, especially after a

paroxysm. Death occurred at 10.20 A.M. on the 4thfrom asphyxia due to spasm of the respiratory muscles.Antitoxic serum, obtained from Messrs. Parke, Davisand Co., was injected in doses of 10 cubic centimetres

every four hours and chloral and bromide were given bythe rectum, but nothing seemed to have any effect exceptchloroform, which was administered during the spasms.The germ must have entered the patie t’s system throughthe placental site, as there was no tearing of the osuteri during dilatation, the uterus was well douched afterbeing emptied, and the strictest asepsis was observed

throughout the operation. The patient’s house was situatedin the country but there had been no case of tetanuseither in human beings or lower animals anywhere in theneighbourhood for years. Puerperal tetanus in this countrymust be rare and, as I see from the text-books, is attendedwith a very high mortality.

Beverley.

PILOCARPINE AND THE MENTAL FACTOR.

BY WILLIAM ROPER, M.A. OXON., L.R.C.P., L.R.C.S. EDIN.

PROFUSE perspiration is frequently a means of savinglife and the only drug always to be relied on for this purposeis pilocarpine. It seems to me, therefore, of great import-ance that the danger attending the exhibition of this drugshould be clearly present to our minds. For there is

certainly a danger in any impediment to vigorous expectora-tion, especially when sialagogue action is well mtrked,although this impediment may not be strictly physical inits cause. A frequent use of the drug in full and some-times large doses has led me to the conclusion that the

dangerous symptoms sometimes seen are mental in origin.This view is illustrated in the following case, where theonly bad effects of which I have ever had experience(and I have given two-thirds of a grain hypodermically morethan once to people in worse physical condition) occurred.The patient took one-third of a grain of pilocarpine nitrateby the mouth in bed one night with excellent effects and thenext morning he took one-twelfth of a grain, or one-quarterthe p.evious do;e, and went about his duties, which weremilitary, under conditions of no particular exertion. Vigorousexpectoration of saliva was, however, inhibited with theresult that he was soon in a condition of collapse whichfortun lately passed off without any permanent bad effect. Iwas most careful to take particular note in writing of thedoses, so that it might be observed that the dose attendedwith bad effects was one-quarter of what was taken withgood effect the night before.Bridport.

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Medical Societies.MEDICAL SOCIETY OF LONDON.

ResultIJ of Operation for the Radical Cure of Hernia.-A7Igio-sarcoma of the Breast.

A MEETISG of this society was held on March 26th, SirLAUDER BRUNTOX. the President, being in the chair.Mr. J. HfTCHiysoN, jun., read a paper on the Results of

Operation for the Radical Cure of Hernia, which we hope-hortly to publish in full.-In the discussion which followedMr. F. S. EvE said that in the early part of the year 1899he wrote to all the patients upon whom he had operated forthe radical cure of inguinal hernia between the years 1888and 1898 inclusive. The total number of cses operated or.

was 141. This total was made up as follows : Baasim’soperation, 71 cases ; Macewen’s operation, 15 ; ligature ofthe neck of the sac in adults, 26; and operations on childlenunder the age of ten years, 29. Of the 112 adults operatedon not one died ; of the pa’ients operated on by Bassini’smethod, 40 were seen and were available for statisticalinquiry. Of these, three had recurred, a percent agre

904

7’ 5. Of the cases operated on by Macewen’s methocall occurred prior to 1894 and too small a numbe;reported themselves to be of any value. Of the 2(cases treated by simple ligature of the neck of th<sac, 24 of the operations were performed prior to the

year 1896. Since then he had in every case employeeBassini’s method. All of these patients were under 29 yearsof 2ge and the simpler operation was adopted because thehernia was small, the internal ring narrow, and the obliquityof the canal not lost ; or the operation was performed fOIstrargulation and it was not advisable to prolong it. Ofthese 26 cases 16 reported themselves, with three recurrences,being a percentage of 18’7. In the majority of cases ofBassini’s operation kangaroo tendon was used for the deepsutures. Latterly, however, Mr. Eve had used silk withequally satisfactory results. Of the 29 cases operated on inchildren under ten years of age, 17 were under two andfive under one year of age ; in four instances the hernia wasstrangulated. No patient died as a result of the operation, butone contracted diphtheria and died in a fever hospital. 20 ofthese cases were available for statistical purposes and onlyone had slightly recurred, making an average of 5 per cent.of recurrences. 18 of those cases were treated by ligatureof the neck of the sac, and two were operated on by Bassini’smethod.-Mr. H. J. WABIN&, referring to the recurrence ofhernia after radical operation, said that the great majority ofrecurrences were those in which suppuration had taken place.The percentage of recurrences was less in congenital thanin acquired hernia. After ventral or umbilical hernia atruss was often, but not always, necessary. Kangarootendon was not so satisfactory as silk or chromicised catgutin his experience. In femoral hernia the results very muchdepended on what kind of operation was done.-Mr. T. H.KELLOCK drew a distinction between completely or partiallyreducible hernia. He also emphasised the necessity ofremoving the omentum and other contents of a hernial sac.The weakening of the external oblique muscle by slitting itup, as in Bassini’s operation, was responsible for a certainproportion of recurrences. He declared himself in favour ofsilk for the deep sutures.-Mr. HUTCHIXSON replied.Mr. H. BETHAM RoBlNSON described a case of Angio-

sarcoma of the Breast, which was removed from a marriedwoman, aged 38 years, who had had no children, inDecember, 1904. The growth had been noticed accident-ally in the right breast three months before and had pro-gressed slowly without pain. At the lower part of thegland close to its margin was a wedge-shaped nodulatedlump of the size of a small hen’s egg; its edge was fairlywell defined and it was rather elastic. It was not adherentto the skin or fixed to the deep tissues and there was noretraction of the nipple. No enlarged glands were to befelt. There was no alteration of temperature. The patient’sgeneral health was good and there was no loss of flesh. Thewhole breast was removed and the axilla cleared out, theglands in the apex of the latter proving to be slightlyenlarged. On section the growth was of a reddish colour,soft, and granular, with a definite capsule from whichfibrous septa passed inwards. Histologically the growthproved to be round-celled sarcoma specially grouped roundvessels, the cells being held together by a reticulum re-

sembling lymphoid tissue ; the tumour was therefore an

angio sarcoma. The enlarged glands that were examinedshowed no secondary deposit. This form of tumour was veryrare and descriptions of it were very scanty. The case waslike others described by Schmidt. 1

PATHOLOGICAL SOCIETY OF LONDON.

IJYSB’I1te’l’Y in SU1dh -4frica.-On the Phagocytosis of Baoill’!!sTyphosus &mdash;A Simplified Method of enumerating Leuco-cytes.&mdash;Demonstration of the Und2Elatiny Membrane ofSpiroch&aelig;t&aelig;.A LABORATORY meeting of this society was held at the

Royal Army Medical College on March 20th, Lieutenant-Colonel W. B. LEISHMAN, R A.M.C., beivg in the chair.Lieutenant-Colonel C. BIRT, R.A.M.C., read a paper on

Dysentery in South Africa. He said that armies in thefield had hitherto been always attacked by dysentery whichhad caused a mortality of from 5 to 10 per 1000 strength.The war in South Africa was no exception. Among the

1 Langenbeck’s Archiv f&uuml;r Klinische Chirurgie, Band xxxvii., p. 421.

necropsies which he had made 58 deaths were due to

r dysentery and 188 were due to enteric fever. With im-

3proved sanitation consequent on cessation of hostilities theincidence of the disease had become much reduced amongthe troops, but it was still prevalent among the civil popula-

tion. Nearly one-sixth of the deaths in Jobannesturg were; recorded under the headings of "dysentery," "enteritis,", and "diarrhoea." Lieutenant-Colonel Birt isolated Shiga’s

bacillus in 26 cases of dysentery out of 55 examined. The, method adopted was as follows. (ttwill be noted that man-, nite fermenters were excluded by it). A stool from a patient

in the early stage of the disease was selected as free from, faecal matter and urine as possible, and examined imme-. diately for living am&oelig;b&aelig;. These were found once only.

Bruce, who carried out investigations during the war, wasunsuccessful in his search for them. Beveridge detectedthem three times in 143 patients. A fragment of the blood-stained mucus was washed in sterile normal salt solu-

tion, transferred to a second tube of this fluid, and shakenvigorously. As a rule, no further dilution was necessary.The bacteria incorporated with dysenteric slime were notnumerous. Plates were made of this on Drigalski andConradi’s medium, taurocholate neutral red, crystal violetlactose agar, lactose litmus agar, or ordinary agar (+ 25Eyre’s scale). Next day the more delicate colonies weretransplanted into Doerr’s modification of l3anilkow’s mediumwhich consisted of nutrose, mannite, litmus, and water.Shiga’s bacillus left this unchanged. The colon bacilluscurdled and turned it pink. Subcultures from the unalteredtubes were made on agar which, if they proved to beGram-negative rods, were put up in sedimentationtubes with the patient’s serum, normal human serum,and with the serum of an animal immunised withShiga’s bacillus. In several instances almost pure growthsof Shiga’s bacillus were obtained directly from the dysentericmucus emulsion. These were compared with Shiga’s,Flexner’s (mannite non-fermenting), Vaillard’s, Bruce’sSouth African, Firth’s South African, and Indian strainsand were found to possess similar cultural characteristics.All the above and eight isolated by Lieutenant. Colonel Birtwere found by Eckersley and him to be flagellated whendeeply stained by Li5ffler’s method. Among the 55 caseswere ten infants. Shiga’s bacillus was obtained fromseven. Clumping reactions were not always very marked.The highest dilution noted was 1 in 600. The usual figurewas 1 in 20-50. Normal human serum was without effectin a 10-fold dilution. The agglutinating power of theblood was not of long duration. The patient’s blood,which reacted up to 1 in 600 on the twelfth day, agglu-tinated the bacillus in a 20-fold dilution only on the fortiethday. The post-mortem appearances consisted generally ingreat nodular infiltration of the lower part of the largebowel. The summits of the bosses became gangrenous and

large excavated ulcers were formed. In about one-eighthof the cases the lower part of the ileum was invadedwith a diphtheritic-like layer. Multiple suppurations ofthe liver were found in one-half of the bodies. In the

necropsies in which a bacteriological examination was

made the spleen was sterile and the liver abscesses con-tained the staphylococcus pyogenes aureus only. Entericfever predisposes to dysentery. There existed either a historyof that fever or lately healed or unhealed typhoid ulcers inhalf of the patients who succumbed. The anti-dysentericserum prepared by Dr. J. L. Todd at the Lister Institute ofPreventive Medicine was used in three cases in which Shiga’sbacillus was isolated with the best results.

Captain W. S. HARRIsoN, R.A.M.C., read a paper on thePhagocytosis of Bacillus Typhosus. After giving a briefepitome of the work of Wright, Douglas, and others on" opsonins " and of Leishman on " stimulins,"he drew atten-tion to the fact that, contrary to what happened in the phago-cytois of staphylococci and tubercle bacilli, in dealing withtyphoid bacilli the use of a heated serum in a phagocytosismixture almost always gave a higher phagocytic index thanthe use of an unheated serum. This was probably due tothe effect of bacteriolysis which reduced the number ofbacteria available for the phagocytes to ingest. In order toobviate this effect, which might possibly mask the presenceof a thermolabile opsonin, he first treated the serum withstaphylococcus in order to rid it of its complement and hethen compared the phagocytic activity of a serum so treatedwith that of one which had been heated after the saturationwith cocci ; he found that he got practically identical results-from heated and from unheatEd staphylococcus-treated