I 238 vY BJOVB] EDINBURGH OBSTETRICAL SOCIETY.
[JUE 6, 194
ON
MEDICAL AND SURGICAL PRACTICE IN
HOSPITALS AND ASYLUMS.
DAVID LE WIS NORTHERN HOSPITAL,
LIVERPOOL.
A CASE OF ACETANILIDE POISONING.
(By HUGH S. PEMBERTON, M.B., Ch.B.Liverpool.)
A WOMiAN aged 29 was admitted suffering from intense
cyanosis- of the face, neck, and hands, frequent'' shallow
respirations, and extreme cardiac feebleness and ir-regu-
larity.' In a few hours the cyanosis and dyspnoea
de6pened, and consciousness was apparently lost. The
temperature was 96.60 F., 'the pulse 84, and the respira-
ti6ns varied'between 35 -and 40. The conjunctival and
abdominal reflexes were obtained, and the knee-jerks
were' slightly increased. The patient' gradually' sank into
a comatose condition, with 'periods of irregular dyspnoea
almost of 'a Cheyne-Stokes'charadter. Oxygen, hot coffee
per rectum, 'digitalin, str'ychnine, -and strophantbin'were
given; in twelve bours the condition began rapidly to clear
up, the cyanosis disappeared, and the patient became more
fully conscious.
During the next twelve hours the patient vomited con-
tinu'ally. The urine was scanty and da-rk brown in colour.
T-he oliguria and symptoms of gastro-enteritis lasted five
to six days, but the urine appeared nornmal within twenty-
four hours. No other signs of acute toxic nephritis
developed.
Among the patient's belongings a considerable quantity
of a flaky white crystalline powder was discovered, which
bore a general resemblance to the drugs of the antipyretic
group. On warming with alcoholic -potash and chloroform
it gave the phenyl isocyanide reaction; this reaction was
negative in several specimens of vomit and urine. - A
spectroscopic examination of the urine showed the
characteristic band of methaemoglobin between C and D. '
EDINBURGH OBSTETRICAL SOCIETY.
AT a meeting on May 13tll, Sir HALLIDAY CROOM, President,
in the chair, a 'discussion was held on Dr. J. W. BALLAN-
TYNE'S paper on Still-birth8 registration. -At the outset
Dr., Ballantyne said that his paper was really a considera-
tion of terminology, but the terms discussed had a practical
bearing and not merely' an academic 'interest. The
difficulty lay in the terms "'still-birth " and " dead-birth,"
and with their equivalents in foreign languages. In their
use there was great' confusion. The great problem
standing in the way of definition was that in many cases
one had to wait before beiing sure that any given birth was
going to be a -live-birth or not. His explanation of the
confusion was (1) a lack of adequate recognition -of the
physiology of ante-natal life and of the changes which
occur 'or may occur at birtlh, and (2) the habit' wllich the
public, with the connivance of the profession, and the
profession itself in some places, had got into of regarding
still-birth as a'synonym of dead-birth. As Parliament was
soon to bring in legislation dealing with " still-births " and
their registration, it seemed well to discuss the terminology
before 'the words " still-birth," " dead-birth," "'live-birth;"
etc., were finally crystallized along erroneous lines. The
d'efinitions he had drawn up had been unanimously adopted
by the council of the society. Dr. LESLIE MACKENZIE (Local
Goveinment' Board) felt that three things hung together-
the notification of births, the proper' regulation of mid-
wives, and the'whole'question of infant mortality. Whien
the notification of births becanie universal, it would mark
an' advance.' The' Local Government Board had practically
decided, where the Act was not adopted; to have it done
by themselves.' He 'thoughit that along these 'lines the
providing of proper training of midwives in connexion witlh
the Midwives Act would be good. It should include
definite and special teaching on such aspects of the
pathology of still-births as were desirable. He had some
doubt as to whether the distiuctions which Dr., Ballantyne
had made, though scientifically necessary, were of practical
value. In spite of the risk of confusion, he thought that
a vast amount .of useful information could be got, even
though some considered still-birth,one thing, live-birth
another thing, and dead-birth another thing, while others
did not 'differentiate sufficiently between them. He
thought that even a limited amount of statistics in the.
hands of good men, such as' the local authorities of
Glasgow and Edinburgh, would be of g'reat value. If the
Registrar-General had-to distinguish five forms of tuber-
culosis and,two or three forms of pneumonia,- it was not
asking very much for medical men to make these dis-
tinction's as regards births. Dr. J. C. DUNLOP (Registrar-
General's Department). agreed with Dr. Ballantyne as
regards' the - general lines he had- laid' down. He
considered, however, that'notification, not registration,
was the best method of acquiring and co-ordinating thc
information, because regi'stration was not a'n administrative
machinery for.the production of vital statistics. These
were aby-product. Registration was done by men with no
medical knowledge, and there' was'no medical super-
vision by tllis' machine until it was too late. to' makie any
inquiries which might be necessary under these circum-
stances. In regard to notification there was,' however,
complete medical supervision. The registration of theso
cases, moreover, did not fit in with the established system
in Scotland. There were tllree registrationfs marriages,
deaths, births. The,birth register onlv dealt with clhildren
who lived, in order'tthat they might have,'when-they grew
up, their civil rights established. If one introduced other
registers for miscarriages, dead-birtlhs, anid still-births, lhe
feared the ordinary systemi of registration would be upset. He
would suggest three considerations why the medical office]
sho'uld bb directly no'tified . (1) The information,was se6cret;
(2) thd information was passed on to a man with the technical
knowledge necessary to appreciate it, and (3) it in no way
complicated the present system. Professor LITTLEJOHN
thought that 'the chief function of statistics- was not purely
civil; registration had been 'influential in the direction of
preventive medicine. He thought that Dr. Ballantyne's
definitions might be simplified. They wanted to know,
firstly, of the existence of abortions and dead-born children.
Let there be a general notification of dead-born children,
whether they had died some weeks before or during' birth.
This admittedly did not give all the inform'ation thev
wanted. But how were they to discover in ordinary cases
whether a child died of syphilis, from the cord being r'ound
its neck, or from other birth causes? Secondly, they
wanted a record of live-born children. He doubted if
" still-birth " was a useful definition. Many causes mighlt
give ris'e to it. If it became alive by tlle skill of doctor or
midwife it should be called live-born. Dr. BERRY HART
thought that one could not limit the utility of registratioon
to its civil value. It would give information regarding the
causes of fetal death, syphilis, rickets, etc. He agreed that
it was doubtful if' the introduction of " still-birth " wo'uld
be of any value. If a child lived only a few minute's 'it
should be classed as dead-born; if it was still-born and
lived for days it was a live-born child.' As to-' abortions,
he thought the statistics would be worthless. Dr. KEPPIE
PATERSON thought that " still-birtlhs notification" would
cover the case better. In maternity hospitals and in
dispensary practice the information sent to the medical
officer of health would be valuable'; not so 'as regards
private practice generally. Many dead-births were
syphilitic in 'origin, but' the majority of those giving
evidence before the Commission on Venereal Diseases
were against compulsory notificati'on. If the doctor were
compelled to notify an abortion or dead-birtlh as syphilitic,
there would be trouble. The husband w6uld deny' "t 'n'd
would refusei a Wassermann test. And if the 'Ae of
dead-births was not to' be put- in, where was the''IMW" of
the statistics? Dr. A. H. FREELAND BARBOUR thought
two classes of cases bad to- be distinguished: those in
which the child died in utero and was expelled subse-
quently, a;t-what time it did iiot matter, and those in which
the child died during the'process of labour.- Dr. JAMR5
RITCHIE advocated the compulsory tmotification of birth;s
after twenty-eight weeks' gestation.' Dr. HIAIG FERGUSON
thought~that the idea of " still--birth " was so firmily
 TJI11'E 6, 1914-] ROYAL SOCIRTYY- OF MEDICINE.
'stablislied in the popular belief tlhat for practical purposes
it Would be well to retain it. Dr. BALLANTYNE, in reply,
thoughit that notification miglht be the better method, but
it would require serious consideration. He agreed it would
be well if one could simplify tlle classification to include
only dead-birth and live-birth, but there waps a danger of
losing scientific precision if one simplified too much.
ROYAL SOCIETY OF MEDICINE.
SECTION OF DERMTATOLOGY.
AT a meetino on May 21st, the President, Dr. J. J. PRINGLE,
in tlle chair, tlle PRESIDENT shlowed a man, aged 64, wlho
lhad suffered from mycosis fungoides since 1896. The first
symptoms consisted of mycotic tumonrs on the face, whicl
were removed surgically about 1900. Subsequently the
disease became generalized over the trunk and limbs, but
lhad been controlled in a remarkable manner by very free
administration of x rays and latterly by prolonged ex-
posures to a strong arc lamp. Despite the unusually long
duration of the clisease, his general healtlh was practically
unimpaired. Dr. S. E. DORE: A man, aged 63, wlho pre-
sented a patclly erytlhematous and somewhat infiltrated
eruption overthe trunk and limbs of two and a lhalf years'
duration. The lesions, were in many instances crescentic
and slhowed central inivolution and raised, pad-like peri-
phery; this suggested that they were probably early
mycotic manifestations despite the absence of itching.
Dr. J. H. SEQUEIRA, in a paper on Mycosis fur2goides, dis-
cussed its etiology, on the basis of 13 cases seen by hiimself
and 61 case-histories obtained from literature. Of these
74 cases, 46 of the patients were males and 28 females.
Thle extremes of age at which the disease came under
observation were 15 and 75 years, the thre youngest
patients being females, respectively 15, 16, and 17
vears old. Traumatismn was the apparent determining
cause in two of the recorded cases, but in most in-
stances the patient lhad enjoyed good health up to the
onset of the malady. Mycosis fungoides lhad been variously
believed to be a granuloma, a form of sarcoma,.cutaneous
lymplhadenoma, and lymphosarcoina, but' was really a
malady smi generis. In diagnosis blood examinations
were of no assistance, but sometimes the diagnosis could
be established in the pre-tumour stage on (a) clinical
grounds or (b) the histology of the lesions. Infiltration
and the tumours could be removed, suffering relieved, and
life prolonged by x-rav treatment, but no real cure could
be obtained. Death in some cases might be due to meta-
stases in vital organs, but diarrhoea and general exhaus-
tion weere the usual canses. Sir MALCOLM MORRIS re-
corded two cases which lhad been recently under his care.
The first patient, a man aged 52, was in an advanced
stage of the disease, and, in spite of marked temporary
improvement under x-ray treatment, one of tlle lesions in
the frontal region persisted and eventually caused hiis
deatlh in April last. The second patient, a woman
aged 28, was still under treatment, and tlle disease lhad
been checked and a large nunlber of the lesions had dis-
appeared as the result of repeated doses of x rays.
Mr. J. E. R. McDONAGH discussed the characters of
lymphocytes in tumours of mveosis fungoides, illustrating
hTis remarks by an epidiascopic demonstration; lhe con-
cluded tllat mycosis fungoides was not a disease sut generis,
but merely one ,,La series of affections of the lymphatic
system; also that its diagnosis in an early stage could not
be made by mere microscopic examination of excised
portions of tissue. Dr. DOUGLAS HEATH (Birminghiam)
said he thought tllat the.multiformity of the cells in all
stages of mycosis fungoides distinguished it fairly well
hiistologically from other granulomata and from the
sarpomata. He also recorded a fatal case of multiple
sarpowuata of the skin, in which the lesions resembled the
`d'_emle'e "variety of mycosis fungoides. Dr. LANCASHIRE
(gIgster) recalled a series of 6 cases which had come
for Lrea ment to tlle Manchester and Salford Hospital for
S3kin Disease somne years ago. They all came during a
period of three or four years, and since then the speaker
lhad seen orly one case a private one-in the early pre-
inycotic stage. The hospital cages were in various stages,
li6stly advanced,.and some with large tumo-urs. All these
cases had been preceded by "dry eczema" plaques, and
all hliad had marked itphing; all had died, but some were
alleviated for a few years by x-ray treatment. Dr. J. A.
[- TNR i2,39
NIXON (Bristol) mentioned the case of a young married
woman. aged 26, wlhose disease began with an eruption
resemnbling tiniea versicolor, and after six montlhs tumours
appeared upon erythrodermic areas. These ttumoinrs
suppurated freely from miiultiple smnall crater-like openings.
The usual temporary improvement followed the applica-
tion of x rays. Autogenous vaccines were tried witlhout
the slightest improvement. Eventually, after two years,
the patient becarme covered from head to foot witlh lhuae
fungatinig tumours, and died suddenly from exhauistion.
The case preser ted no resemblance either to lympihadenoma
or leukaeinia. The blood only showed some leucocytosis,
whiclh nmiglht lhave been accounted for by the suppurativo
process present. Dr. GORDON WARD thought there were
very close analogies between mycosis, leukaemia, and
Hodgkin's disease. All mliglht present anomalous skin
lesions of a nodular nature; all were chronic, reacted well
to x rays at first, but recurred later, and at times showed
enlargemenit of glands and spleen. He would like to hear
more of the histology of glands in mycosis funigoides.
Were the changes spread tlhroughouit the gland as in
leukaenmia, or localized as in a secondary malignant focus?
WVere there any clinical clharacteristics of mycosis glands ?
Finally, was it not possible that some of the deaths frotn
mycosis were really referable to tlle very massive doses of
x rays given ?
SECTION OF LARYNGOLOGY.
AT a meeting on May 27th1, Dr. D. R. PATERSON, President,
in the clhair, Professor GUSTAV KILLIAN gave a demionstra-
tion of Suspension laryngoscop)y on the living subject. In
the first place he demonstrated the instruments and the
component parts of the apparatus required for suspension
laryngoscopy, namlely, the tongue spatula, the suspension
hook, the mouth gag, the counter-pressor, the gallows, the
operating table, and other instruments to protect the
patient from haemorrhage following an operation and tlhe
operator froum expectoration, especially in tuberculous cases.
The tongue spatula in its most recently developed form is
gutter-shaped and fitted witlh movable wings to prevent
the tongue bulging too mucll at the sides. Another form is
a tongu e spatula whicll carries a second one, narrower and
longer, for raising the epiglottis out of the field of vision.
The suspension hook is attached to the tongue spatula.
To prevent the slipping out of the tongue spatula the
point of suspension is made to fall perpendicularly over
the end of the tongue spatula or even in front of it. A
moutlh gag is absolutely necessary, as the moutlh of tlhe
patient must be held continuously open and as widely as
possible. The gag has the form of a bow, wlliclh is fitted
to the lower part of the spatula hook, and can be screwed
up and down. The counter-pressor is used to exert
pressure on the cricoid region of tlle larynx, and
thlereby to bring the anterior commissure of the
vocal cords into view. Tile gallows is the part of
tlle apparatus upon wlicih is suspended the spatula lhook,
and it is screwed to the operating table. The operating
table is constructed to permit the top of the table being
made higher or lower. This is done by the operator him-
self by means of a crank manipulation. One patient sent
for examination was a man with a growth in the anterior
part of the larynx. Tlhe patient having been placed under
the influence of morpliine and scopolamine, Professor
Killian thoroughly cocainized the larynx. Tlle patient
then assumed the recumbent position on the operating
table with the head well over the edge and the occiput
resting on the adjustable support provided for the purpose,
so that tlle help of an assistant to hold the head is no
longer necessary. The various parts of the apparatus
were then adjusted and the interior of tlle moutl,
pharynx, and larynx was illuminated. Tlle suspension
method showed the larynx in general very much as
one sees it in the direct method. An essential differ-
ence is that a complete view is obtained over the whole
larynx, plharynx, and mouth cavity. The immediate
neighbourhood of the larynx projects more plainly, the
pyriform sinuses gape, whilst the arytenoid regions, and
even at times the beginning of the cricoid plate, come
forward from the vertebral column. The whole topograplhy
of the pharynx and larynx can be taken in simultaneously
at a glance. In the discussion which followed the exami-
nation of this and other cases several members spoke of
 2
1 240 THE Bfnwis
MEDICAL JOURNAL ] REVIEWS.
the limitations of botlh direct and suspenision laryngoscopy.
The opinioIn generally expressed was tllat the direct
miethoid was being, practised too indiscriminately, to tlle
neglect of tlhe old indirect metlhod, and that for tlle removal
of laryngeal growtlhs, and more particularly for those
situated in the anterior coimmissure, the indirect metlhod
was preferable, and that the instruments par excellence for
removing suchl growtlhs were the laryngeal forceps invented
and introduced upwards of a quarter of a century ago by
Sir Morell Mackenzie. At the same time it was generally
agreed that suspension laryngoscopy was a method calcu-
lated to render excellent service under definite conditions
and to enlarge still furtlher the limits of diagnostic and
tlherapeutic knowledge. Professor KILLIAN agreed that all
patients were not suitable for suspension laryngoscopy.
Suspension laryngoscopy was demonstrated by Professor
Killian for the first time at tlhe International Laryngo-
logical Congress in Berlin in 1911 and last year at the
International Medical Congress lheld in London.
BRIT'ISII OTO-LARYNGOLOGICAL SOCIETY.
AT a meeting, on May 13tb, Dr. MARTINEAU in the ch1air,
the following were among the proceedings: Dr. WALKER
Woon (1) recorded a case of double acute frontal Sinusitis
dite to the diphtheria bacilluts; 4,000 units of anti-
diphtlheritic serum were given, and followved in three days
by 2,000 units and removal of the anterior enid of both
middle turbinals; subsequent irrigation of the cavities
led to complete subsidence of the acute symptoms;
.(2) slhowed a malleus and incus removed witlh a mass of
chlolesteatomna from the auditory meatus of a patient,
aged 24, wlho lhad nmade no complaint of any dischlarge.
The speciml-en was found while carrying out a routinie
examination. There had been aural discharge in child-
lhood, but nione for the last ten. years. Mr. CHARLES HEATH
remarked that while necrosis of ossicles was so rare that
lhe lhad never found a dead ossicle in an ear, destruction
of these bones by caries was extremely commoln. Mr.
Heath (1) described a case of deafness accompanied by
nlasal obstruction due to an abscess in a mass of adenoids;
tlhere was a free flow of pus througlh both nostrils
during their removal, and rapid and complete recovery
afterwards; (2) showeed a patient who lhad had Acutte otitis
media acconmpanied by vertigo due to swelling of the
tympanic mucous membrane. There had been profuse
diseharge from, and pain in, the ear, both caused by
retention of secretion in the mastoid antrum. The
conservative mastoid operation was performed, and tlle
hearing completely restored. In reply to questions, the
exlhibitor said that during the conservative mastoid
operation lie left at least one-eighltlh of an inch of the
hiinder part of the bony meatus to protect the ossicles and
the clruim-head. As to what conditions justified an opera-
tion, the full answer would take too long, but lhe would
point out that the presence of unmistakable evidence of
tympanic ehanges justified operation, because there was
always imiore disease found at operation than could be
previously recognized. Dr. FREDERICK SPICER sh1owed
a laryngeal case for diagnosis. In discussing it, Dr.
JONES said lie did not tllinlk it altogether hysterical
he had known a case of aplhonia for eighteen monitlhs
with a curious croaking voice.
DR. THEOBALD SMITH, professor of comparative
pathology at Harvard, has been appointed dir-ector of the
new department of animal pathology in the Rockefeller
Institute for Medical Research in New York. Dr. Theobald
Sniitlh's name is well known to all workers in the fields of
pathology and bacteriology.
THE twelfth International Congress of Ophthalmology is
to be held at St. Petersburg in August, under the presi-
dency of Professor Bellarminoff. The proceedings will
comiimence at 10 a.m. on Monday, August 10th, and con-
clude on Saturday, August 15th. Tho organizing secre-
taries for the United Kingdom are Mr. W. H. Jessop, 73,
Harley Street; Dr. George MIackay, of Edinburgh; and
MrX. J. B. Story, of Dublin. Mr. Jessop iS in charge of the
arrangemenlts in viewv for facilitating attendance at the
congress of B3ritish oculists, and he would be glad to hear
as early as possible fromi those who have it in mind to
visit St. Petersburg on this occasion.---
EJUNE 6, 1914
VITAMINES.
DR. CASIMIR FUNK is the author of an interesting volum11e
in German on vitamines.' He has followed up and ex-
tended the pioneer work done by Eykman, Gryns, Fraser
and Stanton, and the Japanese researcher Takaki oIn ti10
causation of beri-beri, and attempted to isolate in a pure
state those active principles which exist in natural food-
stuffs, to the lack of whiclh not only beri-beri but scuLrvy,
rickets, sprue and pellagra are attributed. To these prin-
ciples lhe lhas given the general name "1 vitamnine." There
are vitamines necessary for the maintenance of nutrition,
and otlhers necessary for growtlh. To these last lie is n0ow
especially devoting hlis attention, in tlle hope of tlhrowing
light on the causation of cancer. The production of beri-
beri by a diet consisting of polislhed rice is a signal proof of
man's folly in mieddling with natural foods by milling
processes. Rice is polished to make it look nice, but it is
essential that the rice-eating peoples shall eat the red
unpolislhed rice, and in the miiatter of cooking they must
boil it in a little water, and eat tlle rice with all the water
in it. If this water is tlhrown away beri-beri may result.
" Cured " rice is not much better than polished rice. An
addition of fruit, or potatoes to a polislhed rice diet will
prevent beri-beri, but the most senisible plan suggested for
diminislhing the prevalence of this terrible disease is to
tax heavily all polished rice in the rice-eating countries.
If the poor people of tllis country lived on wvhite bread and
water to the same extent as tlle rice-eating coolies live on
rice, there would occur no less extensive disease amonig
them from lack of vitamines. The observations of Hopkins,
and of Hill and Flack, show that a diet of wholemteal bread
and water suffices to keep pigeons, mice, and rats in lhealtlh,
but that these animnals cannot exist for more than a few
weeks on wlhite bread and water. The introduction of tlle
potato to Europe is said to lhave put an end to tlle epi-
demics of scurvy, and this may be attributed to tlhe fact
tllat it brouglht an adequate supply of vitaiuines into the
winter diet of the poor. A study of the literaturc
concerning raw and boiled milk leads Dr. Funk to the
conclusion that it is scarcely to be doubted that milli con-
tains anti-scorbutic and anti-beri-beri substances. These
are sensitive to lheat, but the amount of destruction by
boiling depends on tlle reaction and the durationi of
boiling. TIie amouint of vitamines in milk is influenced
also by tlle food of the cows. The food given to cows in
winter may be poor in vitamines. alnd theirnmilk miiay
then colntain almiiost nonie. Slhould the supply of vitamiines
be diminiislhed by sterilization, it may easily be replaced
by the additioni of vitamiine-containing substances.
Pellagna is attributed by Funik to the polislling of nmaize
to remove the lhard cuticle. The aleurone laver is removed
durilng the process, and tlle maize impoverished in fat and
vitamines. In an epidemic in Rlhodesia recorded by
Nightingale tlle substitution of unpolished maize in the
diet had an almost magical effect.
Much yet remains to be done in this important field, andl
the reader will find in Dr. Funk's book an excellent suilm-
mary of past researches and stimulating suggestions of
new lines of investigation. Tlle discovery of tllese subtle
food properties has revolutionized our views on diet,
and demands the attention not only of medical nlei, but
politicians, who must consider the necessity of instituting
solme conltrol of modern metlhods of milling and sterilizinig
food and of feeding, so that tlhe health of the community
does not suffer from want of them. The conclusion to be
drawn is that every diet should be of natural food, freslh,
and prepared in no otlher way than by cooking, and that
the water in wllich food is cooked should be taken as soup
or broth in th3 excellent French fashion.
In the last number of the Journca of Physiology,'Dr.
Funk publishes further evidence of the curative power
of the vitamine le has separated from rice polishiings.
This vitamine added to polished rice suffices to keep
pigeons in health while under observation for prolonaed
periods.
Die J'itameinte, ihre Bedeutungo filr die P1hysiologi und PathologJic
mit besonlderer Beriichsichtigung der Avitaminlosenb (Beri-ie,-i,
,Skor-but. Peflagra. Bach1itis). V'on C. Funk. Wiesbaden: J. F.
Bergmanln. 1914. (Sup. roy. Bro, pp. 193; 2 plates; 38 iigures. MW. 8.60.)