Correspondence.

We do not hold ourselves responsible for the opinions of our correspondents.

THE PRESCRIBING OF STIMULANTS FOR PRIVATE INDIAN PATIENTS IN NATAL.

To The Editor, SOUTH AFRICAN MEDICAL RECORD. DEAR SIR,

In a letter received this week from Mr. Guy Elliston, General Secretary of the British Medical Association he expresses his gratification that "so far as you are concerned personally" this question has satisfactorily terminated. I have to express my sincere thanks to Mr. Elliston for the ready and sound advice which he gave in this matter throughout, and to yourself, as Editor of the South African Medical Record, for assisting in ventilating my grievance and supporting me in my endeavour (successful) to obtain justice. Yours faithfully,

To The Editor, SOUTH AFRICAN MEDICAL RECORD. DEAR SIR,

Dr. Turner's letter will arrest the attention of District Surgeons in the Transvaal. It would startle certain lay officials were they privileged to read it.

In your Editorial note you dispose of the contention advanced by Dr. Turner which most approaches to high politics.

Referring to the paragraphs in which it would appear the Transvaal Medical Officer of Health is a champion of his professional brethren, I am bound to say a jury of lay officials and District Surgeons of which we might for the sake of argument make the Colonial Secretary Foreman would agree that he was neither their champion directly or indirectly. They might add a rider indicating the pharisaicial trend of his remarks, and as a tribunal, meet the approval of onlookers if they recommended he should be hanged (metaphorically). His humour (ugly) and his politics (unpalatable) constitute the indirect absence of championship. Reference to this I hope will be condoned, and I only mention it as I believe it largely accounts for the marked absence of influence of Medical practitioners with recognised authorities in the Transvaal, compared with other Colonies.

The Medical Council soon to be elected will no doubt effect an improvement in this direction. The Colonial Secretary himself who is possibly the ablest member of the present Government, jecred in the Inter-Colonial Council at the idea of Medical men being deputed to consider a problem and come to a business like conclusion in a reasonable time. His remarks suggest the idea 66 was he speaking from his experience of the Department of the M.OH. ?" as there is certainly no Medical Department he comes more intimately in contact with.

As a District Surgeon in the Transvaal, I would rather the terms laid down in the tariff be construed by a lay official than by Dr. Turner. I am assuming of course he is aware of, and holds himself responsible for, the conduct of his office.

With regard to Dr. Turner's remarks upon the reports of epidemics of typhoid etc., which fell into his hands in Cape Town, he must have been singularly unfortunate, or may be he is more of a paragon than angels would suspect.

I would advocate the formation of a District Surgeons' and Railway Medical Officers' Association. Even with the interests of Government Medical Officers in the ablest and most sympathetic hands in the shape of Head of Departments, such an association could represent many anomalies and disabilities in a way impossible to individuals. Discussion by an association of this kind would ensure real grievances being strongly set forth and others not so substantial being eliminated. I am, Dear Sir, Yours faithfully,

SCRUTATOR.

ANOTHER ASPECT OF THE RECIPROCITY REGULATIONS.

To the Editor, SOUTH AFRICAN MEDICAL RECORD. DEAR SIR,

Anent the much abused reciprocity regulations of the various colonies. Has it never struck those who read the papers that for many years practically all the charges of misconduct against medical practitioners, by which I do not mean offences against mere professional regulations but those against the law of the land, have been laid against Continental or American graduates. I do not want to be ungenerous, still less to say that because a man is a foreigner he is thereby on a lower moral plane than Britishers. On the contrary, during a good number of years of pract:ce in three colonies, I have met more than one foreign confrere whom I esteemed most highly, but facts are facts, and such a fact as that I mention can hardly be a mere coincidence. I know something about one country from which the bulk of our foreign practitioners come, and my impression is that that country certainly does not send its best men out here, to put things mildly. Now, the United Kingdom, being a natural feeding place for its own colonies, sends just fair average specimens, neither its best nor its worst. This point is worth considering by those who value the good name and fame of the profession. Yours, etc.,

OBSERVER.

DR. CASALIS' HYSTERO-MYOMECTOMY CASE.

To the Editor, SOUTH AFRICAN MEDICAL RECORD. DEAR SIR,

Since writing an account of the Hystero-Myomectomy performed at the Victoria Cottage Hospital, Wynberg and sending the report to press, the patient was seized five weeks after the operation and when all danger of complications seemed averted, with symptoms of obstruction of the bowels. In spite of a secondary operation to relieve the condition, she died five days after of peritonitis. At the post-mortem, the jejunum was found ruptured, about five inches from its duodenal origin.

The bowel had become adherent to the anterior abdominal parietes, which as noted at the time of operation were devoid of peritoneum owing probably to an overloaded stomach followed by violent vomiting (it is noteworthy that the symptoms of obstruction occurred some time after the patient had had a rather hearty meal) a rupture took place, the bowel being torn right across its free border, which had

Notes on New Preparations, etc.

VIROL.

We have received a sample of this preparation. That sample was unnecessary, as our experience of Virol is long and favourable. We have again and again had opportunities of testing its usefulness, with the practical limitation that, for some reason or other, chemists in this country seldom seem to stock it, a point which we commend to the notice of the proprietors. To our mind it is one of the few nutritive preparations about which nothing but good can be said, and we have a lively recollection of a number of cases in which no small amount of kudos came to the prescriber through ordering it. As a nutritive preparation it has, in our opinion no equal, especially in cases of anæmia, asthenic dyspepsia, rickets, and the chronic forms of gastro-enteric catarrh in children. Three cases illustrating its special value come to our mind. One was gastric ulcer in a feeble anæmic young woman, there being no room for doubt about the diagnosis. We obtained the assistance of a surgical colleague and arranged for immediate operation if necessary, and put her for a day or two on rectal alimentation. Then she was fed on nothing but Virol for over a fortnight, subgallate of bismuth being the only drug exhibited. She made a steady recovery, keeping on the Virol, plus other carefully added diet, and became robust and rosy, with a normal count inside two months. Another case was one of a miserable little child with swollen joints, which the family practitioner had diagnosed as rheumatism, and treated accordingly without effect. We hazarded the opinion that it might be "scurvy-rickets," and suggested Virol, without any drugs. A quick and absolute recovery resulted. A third was a neurotic lady, convalescent from an abdominal operation She was miserably performed by one of our best known men. anæmic, refused almost all food, and constantly vomited most of that she did take. She made an absolute recovery under Virol without any drugs. We have also often used Virol to supplement bottle feeding in babies with the most excellent results. It exactly supplies what prepared foods, condensed milk, and even South African fresh milk lack, and is not only much more palatable than C. L. Oil, but, in our opinion, more effective. Children of all ages take it greedily. It keeps almost indefinitely, and the price, which was formerly an obstacle to its general use, has recently been reduced by about one-third. We specially commend it to our confreres who practice in the warm coast climate of the Eastern Cape and Natal. They will find it invaluable in the anæmic troubles so common in such localities.

Yours etc.,

J. LUCKHOFF,

Hon. Treasurer.

Domestic Event.

MARRIAGES.

ALBERTYN-BARRY.-On October 15th, at St. Paul's Church, Rondebosch, by the Rev. A. J. Rendle, Dr. A. J. B. Albertyn, of Caledon, eldest son of Dr. F. Albertyn, of Zeekoevlei, Bredasdorp, to Shirley fourth daughter of Dirk G. Barry Esq., of the Civil Service, late of Her Majesty's 11th Foot.

Reviews.

Lectures on Clinical Psychiatry. By Emil Kraepelin. Translated by Thomas Johnstone, M.D., M.R.C.P., pp. 308, demy Svo. Price 10/6 nett. London: Bailliere, Tindall & Cox.

Anything emanating from the distinguished professor of Psychiatry at Munich commands respectful attention, and these clinical lectures are admirable as a record of extensive observation expressed in clear and lucid style. The "word painting," such a necessary element in writing on this subject, is vivid in the extreme. We think his classification of mental diseases is more rational than that in vogue in England. Especially good is the lecture on Dementia Præcox, and that on Paranoia is very little inferior.

The translation appears to us to be well done, and the book may be read with great advantage, not only by men engaged in alienist work, but by the general practitioner. Many parts of it are as easy reading as a novel.

VOL. II.-No. 12.

Index.

PRICE 1/6

Having practised in Cape Colony for some years and thus knowing something of the conditions and requirements of the General Practitioners there, I may perhaps be excused in directing attention to the advantages of ethyl as a general anesthetic to the readers of this paper, and in these articles hope to review the whole subject as far as space in this valuable paper can be afforded me. It is hoped that I shall not be accused of rushing into and advising for general use a new and untried anæsthetic; on the contrary, whilst practising as an anesthetist first in London and now in Edinburgh, I have had ample opportunity of giving it, in various forms, by various methods and apparatus, and in a large variety of cases, both in private and in hospital practicenumbering over a thousand administrations-and further, having carefully gone into the work and opinions of others, am by conviction assured that the agent under consideration, if properly administered and to suitable cases, will be found for short operations at least, one of the safest and most convenient anæsthetics we possess.

As a preliminary let us enumerate briefly some of the more important advantages and uses of this drug.

First of all-Safety. There can be no doubt that it is as safe as Ether, at least for short operations. For long operations, it has no advant ge over Ether or Chloroform. Seitz collected up to the end of April 1902. sixteen thousand cases of narcosis carried out throughout the world. In these cases there was only one death, that of a very unfavourable subject. Since that time some thousands of other cases have been recorded. Later Dr. T. D. Luke writes, In all the fatalities which have occurred under ethyl chloride-and there are only four or five cases on record-the patient has been suffering from some grave cardiac or respiratory disability, and as Dr. Hewitt puts it in the September (1903) issue of the British Dental Journal we are now entitled to consider "that Chloride of Ethyl is a comparatively safe anæsthetic" as safe all things considered as Ether. I should now put down the mortality at some hing between 1 in 10,000, and 1 in 15,000, but of course, as with all anæsthetics much depends on the experience of the administrator. ... Employed in.its own sphere, namely for inducing anesthesia, prior to Ether or Chloroform, and for brief dental or throat operations, ethyl chloride is undoubtedly very much safer and more convenient than chloroform."

It is not an unpleasant anesthetic to inhale if properly given by means of a suitable inhaler, it is remarkably quick in its action, even quicker than nitrous oxide and in comparison gives a longer period of available anæsthesia and analgesia. Further, the anaesthetic fluid and the apparatus for its administration are not expensive, the initial cost is less than that of a nitrous

oxide outfit. No heavy gas-bottles are required, nor is the apparatus complicated, so that the technique of the administration is simple.

Certain classes of patients take it better than nitrous oxide, notably the very young, the aged, and anæmics, also those with cardiac, pulmonary, and renal affections. Besides being safer than chloroform, it can be given in the sitting posture and may be re-administered if necessary. It leaves little or no smell in the room. Its chief use is in operations lasting up to, say, three minutes, and therefore is best for dental extractions, removal of tonsils and adenoids, and other short throat operations. In ophthalmic surgery, it is exceedingly useful, and in a variety of cases of a gynecological nature. It is not usually followed by marked after effects.

We will now pass on to methods of administration with description of inhalers, and in my next paper hope to give an account of the general course of narcosis, signs of anesthesia, and some practical hints.

A small child can be anesthetised by the simple method of spraying the agent on to a towel or handkerchief made in the form of a cone. A specially prepared felt cone covered with mackintosh can be purchased at the surgical instrument makers, and has been long in use for the semi-open method of giving ether, or for Č.E. or A.C.E. mixture. The only objection to these cones is, they are not easy to keep clean, but nevertheless are very handy for country practice as they take up but little room in the bag, fit the face fairly well, and in giving chloride of ethyl to a child as a preliminary to A.C.E. no other apparatus is required, as the latter mixture is sprinkled on to it after the little patient is once under.

A small Rendle's mask, made of celluloid or metal is easier kept clean, but being rigid does not adapt itself to the face well and thus the induction is slower, there is often excitement and the amount of fluid to be used is considerable.

A folded towel put round the mask at its junction with the face makes it fit better. For the same reason one of the earlier inhalers, known as Breneur's mask which admitted a large quantity of air along with the vapour, and consequently did not admit of re-breathing, was the cause of many failures to anesthetise patients, and which failures were at the time put down to the ethyl chloride.

In adults, therefore, a closed inhaler, in which rebreathing can be permitted, must be used, and I would at once warn my readers not to get an inhaler that does not permit of the drug being given gradually. That this latter is not absolutely essential is shown by the good results of many experienced anesthetists, but I hold this only shows their skill and not the excellence of the inhaler, and I claim that the induction is more satisfactory from all points of view, if the drug is exhibited slowly. The following extract from an interesting paper by Dr. W. Guy, (published by him in the British Dental Journal of April 1904) sums up fairly well the points which should be our guide in the choice of an inhaler, for this is a very important detail.

"I show you a number of inhalers (those shown included Breneur's, Hatch's, Knowle's, Luke's, Daniell's and Hedley's) . . . . I saw all I could see of the work of others, I read all that came out on the subject, I experimented for myself and myself and took careful notes,

and in the result my position is thus:-(I) The dose to be given must be accurately measured. (II) The apparatus must be a simple one, with as few levers, chains or attachments as possible. (III) The employment of lint diaphragms or cotton wool or any apparatus in which the drug is discharged into the facepiece is unsatisfactory. (IV) The dose should be discharged directly into the bag, it should measured with a graduated glass tube, which should be attached to the apparatus before the administration begins. The anesthetist should have nothing to do but tip in the dose, and watch his patient after the facepiece is applied. (V) The result should be so far definite, that for a definite dose a definite result may be expected. (VI) The apparatus should be cheap and easy to cleanse and sterilise, it should also be adapted for use with gas alone or gas and ether in mixture, and must have wide breathing channels."

I think the inhaler I am about to discuss an account of which, after having fully tried it, I published in the Lancet of October 17th, 1903) meets all the points enumerated above.

From an extended experience in the administration of Chloride of Ethyl and Somnoform, it occurred to the writer that the method of administration was capable of improvement and also, that, at least some of the objections to the use of these agents could be overcome by a simple inhaler, a short account of which method and apparatus I am now giving. It is not uncommon to hear patients complain of a choking and suffocating feeling on going under, and I venture to hold that this can in the large majority of cases be prevented, it being caused by the sudden application of a concentrated vapour, and is more noticeable in nervous adults, in children, and those with sensitive or irritable throats. Many patients are greatly alarmed at having a mask applied to the face filled with a powerful vapour. This, not infrequently, causes holding of the breath, coughing, and in some cases is followed by struggling, with consequent delay in the induction of anesthesia. These initial strugglings etc., on the part of the patient may also be the cause of dreams of a disagreeable character, and also in weakly subjects may put an undue strain on the heart and so cause anxiety on the part of the anæsthetist.

Treating now, for the moment, the administration of Chloride of Ethyl (or Somnoform) alone. In most of the inhalers I have seen and used, an estimated dose is first projected on to a more or less extensive surface of lint, cotton-wool, or sponge; inside the facepiece, close to the patient's nose and mouth, and then the mask is quickly applied. In others, a capsule containing either three or five cubic centimetres, is broken inside an inhaler of special construction. The objections to the first class of inhalers, besides that mentioned above, are, that a certain amount of the fluid at once evaporates and is lost for anesthetic purposes and consequently an unknown quantity of the agent is given. Also, freezing takes place inside the mask and often close to the patient's nose and mouth. The objection to the use of capsules is that there is too much restriction of dose. One must use either three or five cubic centimetres. In the case of young children for instance, two or two-anda-half c.c. is often ample to produce satisfactory anaesthesia. Adults seldom require more than three or

four c.c. for one inhalation, and further for prolonged administration a much larger amount than five c.c. may be required, when it is found both inconvenient and wasteful to be frequently breaking capsules.

An inhaler both simple in construction and use is that made by attaching together the facepiece and anglemount of a Clover's portable ether inhaler and introducing the agent through the tap commonly found in the anglemount, used for gas in the nitrous oxideether sequence. A modification of this is described (Dr. Luke's inhaler) and in use the tap being removed flush with the anglemount the hole being closed with a wooden plug.

Having used this "Clover" method a number of times I find the following modifications and methods of great advantage, and venture to submit them to the of administrators. consideration

AUTHOR'S INHALER.

Instead of the hole and wooden plug in angiemount, I prefer the tap with metal tube continuation. The tap is easier to manipulate than a plug and cannot get lost. Also, owing to the construction of some of the trigger-valved ends of the ethyl chloride bottles it is easier to introduce the fluid through the projecting end of the tap than through a hole flush with the surface of the anglemount, especially is this so if the patient is inclined to move. At the commencement of the inhalation instead of projecting the fluid through the tap directly from the bottle, I first measure out a definite quantity into a small tube made of thick glass, which for the sake of accuracy I have marked in three, four, and five cubic centimetre graduations. To this small measure-glass is attached a short piece of red rubber tubing by means of which it is accurately attached to the end of the tap of the anglemount. (vide illustration.)

The following is a summary of the advantages of this inhaler and method of administration :

1. A measured quantity of the anaesthetic fluid is given, varying according to the age of the patient, and taking into consideration the time of anaesthesia required, the nature of the operation, etc.

This gives accuracy of dosage, and is useful for making observations and notes for future reference. It should also help to insure against an overdose.

2. The anaesthetic can be given gradually, and that after the facepiece is adjusted; this prevents coughing, holding breath, etc., and produces a satisfactory induction.

3. More can at any time be added if necessary, either by projecting the fluid through the large open tap, or by measuring off more into the tube; also, either can be done without having to remove the facepiece, which is an advantage in some cases in which air exclusion is necessary. One the other hand, the tube need not be emptied if satisfactory anesthesia is likely to be produced by less than its contents. In hospital practice this is kept over for the next case, for purposes of economy.

4. In the event of voluntary struggling-as is sometimes the case in children and very nervous subjects-it is easy to empty the tube by tipping it up with one finger, both hands being available to hold the mask and steady the patient.

5. If the tap is turned off before the tube is fixed on, the patient will not experience the slightest smell of the narcotic when the mask is applied. This is of importance in nervous patients.

6. A perfectly free air-way, no lint, sponge or wool, to breathe through, and no freezing vapour near the patient's mouth or nose, as all evaporation takes place in the metal tube and rubber bags.

7. Nitrous oxide can be given as a preliminary.

8. By retaining the ether chamber these drugs can be given with ether or used as a sequence; all that is necessary is the glass tube.

9. Bromide of ethyl can be given with advantage by this apparatus, as it is important to be able to measure the quantity of the drug.

10. Economy in the amount of anesthetic used.

I have given chloride of ethyl by this method and apparatus using the paper bag-invented by Mr. Rickard W. Lloyd, and made by Messrs. Barth & Co.-with satisfactory results, and recommend its use (instead of the ordinary black rubber ones) in the case of patients suffering from tuberculosis, or any marked septic condition of the mouth or air-passages. In purchasing a new apparatus, it is as well to have the bag and facepiece of red rubber, as it stands sterilisation, and as far as my experience goes these drugs have no action upon it. I would state that I have used this apparatus and method over five hundred times with satisfactory results. The inhaler is made by Messrs. Mayer and Meltzer, of London, and they tell me that they have it in their Cape Town house. (To be continued).

This paragraph is written to prove that even a doctor will sometimes turn. A man called upon one not long ago to be examined. The doctor examined him, and wrote out a prescription. When told what his fee was, the patient asked to be allowed to owe it, as he was short of funds. The doctor acceded to this request. The man then asked what it would cost to have the prescription made up. On being told that it would cost about five shillings, he asked the doctor if he would kindly lend him the amount. This was just a little too much for the man of medicine. He seized the prescription and said "This prescription will not do in your case. I have evidently made a mistake in diagnosis. I have treated you for weakness of nerves."-Daily Chronicle.