Reviews.

CHAS. J. HILL AITKEN, M.D. [Our diagnosis certainly coincides with that of our correspondent, and we speak not without local experience. For some reason or other, tick bites produce an unusual amount of febrile disturbance in people unused to the coast climate of the Eastern Districts and Natal. The explanation probably lies not so much in the tick bites themselves, as in the fact that the warm, saturated atmosphere interferes with cutaneous elimination, and renders the skin, for the time being, highly sensitive. We have found citrate of potash and saline purgatives internally, with hot dry flannels locally, the best treatment.-ED. S.A.M.R.)

MILD ENTERIC UNDIAGNOSED.

Dr. J. H. Saunders, evidently a gentleman who served in the late war, writes from Sydney, New South Wales, expressing his entire agreement with the view advanced in the recent paper on Enteric read at the late S.A. Congress, to the effect that most of the cases diagnosed as Simple Continued Fever were mild enteric. He says that he formed his opinion from observation of large number of cases in three colonies, especially at Kroonstad, and hopes this will be instilled into the military medical mind next campaign.-ED. S.A.M.R.

MONSONIA IN INTESTINAL HÆMORRHAGE.

a

In reply to several correspondents who have written for information with reference to the above drug and its mode of administration, we beg to state that it is given as prophylactic in dram doses four hourly, combined with quinine or anything else one is administering, and when hemorrhage has actually occurred, in dram doses or more, two hourly or hourly, in combination with opium. We refer to the commercial Tincture of the Monsonia Ovata, which can be obtained from any of the wholesale chemists in Cape Town. We have, however, found a Liquid Extract of the Monsonia Biflora, when obtainable, more effective in the same doses, and Dr. Maberley informs us that a similar preparation of the Monsonia Burkei is still better.-ED. S.A.M.R.

Notes on New Preparations, etc.

OPPENHEIMER'S HYPODERMIC CASE.

We have received from Messrs. Oppenheimer, Sons & Co., Ltd., one of their very convenient hypodermic cases. It is one of the best we have seen. It is strongly made of gun metal, and of a size admiting of being carried in the waistcoat pocket. One very great convenience is that the plunger is readily expanded by a turn or two of the piston rod, and another is the ease with which the tubes are got at. They are contained in a rack, holding 17 tubes in two rows, and when this rack is placed vertically each tube is readily seen and accessible. Another important advantage is that the needles, of which there are two, are stowed in such a way that their points are quite safe from injury. And lastly, these needles can, by screwing the nozzle of the syringe into one whilst in situ, be replaced or withdrawn without being touched by the fingers, thus ensuring perfect asepticity. The whole thing is a marvel of compactness. W.D.-H.

Diseases of the Gall Bladder and Bile Ducts. By A. B. Mayo Robson, F.R.C.S., assisted by J. F. Dobson, M.S., London, F.R.C.S., Third Edition. Pp. 485, demy 8vo. Price 15- nett. London, Bailliere, Tindall & Cox.

The latest edition of this well-known work differs markedly from its predecessors. It is more than doubled in size, and includes several new chapters, as well as an appendix containing a more or less brief account of all the operations, 539 in number, performed by the author on the gall bladder and bile ducts. The book was originally a reproduction of the Hunterian Lectures given by Mr. Robson in 1897, and this has been amplified and added to in each successive edition. A chapter on the physiology of the biliary secretion has been embodied, and is chiefly composed of a reprint of the author's communication on the subject to the Royal Society several years ago. In this connection it is well to remember that experimentally no substances having definite cholagogue effects have at present been detected. The prevalence of typhoid fever in this country adds additional interest to the marked influence which the disease is known to have on the incidence of certain diseases of the biliary passages. Mr. Robson has introduced many well-known modifications in the operation for gall stones, which have greatly facilitated their removal from the common hepatic ducts, and it is interesting to note that he uses no special instruments except a perfectly simple curettelike scoop, and that he sews up the ducts with a curved needle without a holder. We note the very low mortality obtained by the author in gall stone operations, and, although we readily acknowledge that an uncomplicated cholecystotomy, or even choledochotomy, in ordinarily skilled surgical hands is practically devoid of danger, yet there always is, and will be, a varying but definite mortality or risk attached to complicated operations for these diseases, which are met with proportionately much more frequently by general surgeons than by the expert, as the latter treats a much larger proportion of uncomplicated cases. The volume contains the accumulated experience of the author in this class of surgery, in which he is acknowledged authority. The context is profusely interpolated with illustrative cases, and the whole work strikes a markedly personal note. Although it cannot be recognised as a complete or elaborate account of the subjects dealt with, and is hardly suitable for the use of the untrained student, yet in the hands of those having some surgical experience of these diseases, it is full of excellent practical knowledge and guidance, and should be carefully studied by those who may be called upon to deal surgically with these diseases.

an

Domestic Events.

MARRIAGE,

S.W.F.R.

OSLER - GEERINGH.-April 5th, at All Saints Church, Somerset West, Thos, Osler, M.B., Ch. B., of Robertson, to Hetty, elder daughter of Henry Geeringh.

VOL. II.-No. 5.

Index.

PRICE 1/6

I place mechanical causes first, as being the most frequent. They may be divided into those with the presence of a foreign body and those without. A common cause of injury to the cornea is a finger scratch often produced in mothers by the nails of their infants, which are frequently septic. Again there may be scratches from a coarse towel. Forks used as bootlace openers may slip and cause a large penetrating wound, generally involving the loss of eyesight. An exploding sparklet apparatus has caused rupture of cornea and bulb, and a similar injury may be caused by the blow of a fist, or a whip, cricket ball, needle or thorn, may be the offending instrument. In one case under my observation the edge of a photographic card produced a lesion in the pupillary area, with resulting keratitis and iritis lasting for over a month. A few cases have been recorded of injury to the cornea by forceps during

labour.

By far the most common injuries are those in which a foreign body is found in the eye. So great is this preponderance in certain districts, that, according to the dictum of an ophthalmic surgeon in a manufacturing town, he made the most of his living by removing foreign bodies from the cornea. These injuries are usually connected with the calling of the sufferer, and on being informed of his trade, the nature of the foreign body can generally be presumed. With reference to these trades, first and foremost would probably be found the metal workers, as fitters, blacksmiths, tool makers and finishers, trades in which the emery wheel is almost in constant use, and from the surface of which particles of steel or emery are often being projected into the faces of the workers. These injuries may, or may not, be severe, but our experience is that, although they are most frequently small in area and moderate in severity, they may, and often do, leave very troublesome leucoma or nebula. Occasionally even more severe results may occur, such as penetrating wounds of the cornea, lens, choroid, or retina, followed by hæmo-ophthalmos and detachment of the retina, or retention of the foreign body may happen.

In the fact that these injuries are not usually severe, they differ from those met with amongst stoneworkers, more especially quarrymen and masons, who strike their friable materials with great violence. Undoubtedly in connection with these occupations are seen the more severe injuries, attended frequently with the loss of an eye.

Millers, again, are amongst those workers who suffer from the impaction of small particles of stone, iron, or steel, in the eye, whilst dressing the milling stones.

Blacksmiths, besides being injured by flying particles of cold iron, frequently suffer from a mixed injury, a

burn plus the impaction of a hot iron scale. These injuries call for very skilled treatment, as acute keratitis not infrequently follows them. The foreign body must be immediately removed, and soothing applications, such as atropine and ice cold compresses, must follow. Fortunately suppuration very seldom supervenes, probably owing to the fact that the offending particle is itself antiseptic, and cauterizes the surrounding tissues.

Agriculturists, such as farm labourers, wood cutters, fruit growers, &c., sometimes come to the ophthalmi: surgeon suffering from injuries to the eyes due to thorn wounds, abrasions from boughs of trees, obtained whilst dressing and brushing hedges, or fruit picking, or to stings of insects or blows on the cornea from the hard and sharp seeds of cereals or from the upstanding corn whilst reaping or threshing.

In this country the wind blows with such force as to lodge in the eye foreign bodies, such as small particles of stone or dust. Railway and motor car travellers are liable to get into their eyes particles of sharp siliceous cinder, dust, or stone.

Glass is sometimes found as the result of exploding mineral water bottles, or of spectacles being smashed whilst being worn.

Eye lashes have been found penetrating the cornea. and are very difficult to remove. So have the hairs of caterpillars, causing small nodules, ophthalmia nodosa, and a chronic keratitis very difficult to cure.

The most frequent position of a foreign body, according to statistics, is in the middle of the cornea, and next in frequency in the lower segment. The reason for this is probably that the lids, forming the palpebral fissure, protect the upper and lower limbs of the cornea, whilst the central inner or outer meridians or axes of the cornea are exposed to the flying particles. The foreign body is often difficult to see, requiring careful examination by focal illumination, and a practised eye. The enlarged black pupil after cocainisation, makes it difficult to see a dark foreign body, visible before. It is possible, however, to overcome this difficulty by adding to the cocain solution some eserine, which contracts the pupil, whereupon the foreign body shews up again. This mixture, however, causes a good deal of pain when instilled.

Wounds may be abraded, punctured, penetrating or lacerated.

Abrasions are caused by scratching with nails, rubbing with coarse cloths, foreign bodies, &c. The symptoms are photophobia, great pain, and lachrymation. On examination one finds a marked pink ciliary injection and a deficiency of epithelium, which, as the seat of the injury is transparent, can mostly only be detected by reflecting light on the cornea, when the uneven surface will shew up, or by applying fluorescine, which, however, is usually superfluous. Under proper treatment these abrasions soon heal and. if Bowman's membrane be not penetrated, do not, as a rule, cause nebula. However, they may become the seats of ulcus serpens or ulcerative keratitis, in case a diseased condition of the conjunctiva or lachrymal duct be present.

Punctured wounds made by needles, thorns, scissors, &c., are often very dangerous on account of the risk of septic infection, which may be followed by hypopion, iritis and panophthalmitis.

Penetrating wounds are a severer form of punctured, caused generally by greater violence and larger foreign bodies. This form of wound has c'ean cut edges. The iris is often prolapsed, and frequently wounded, also the lens, and post-retinal hæmorrhage is not uncommon. The danger is generally serious, especially if the wound. be situated at the sclero-corneal junction, and the dangerous area (the uveal tract) involved.

Lacerated wounds are frequently due to explosions and blows on the eye. Under this category comes rupture of the cornea, which may be both lacerative and penetrative. The whole eye is implicated, and generally removal of the globe indicated. I may here mention contusion of the cornea, under which may be reckoned the before mentioned forceps injury. This produces a keratitis profunda, which, however, clears up rapidly.

The

As to complications. After abrasions the most common is keratitis, and again there may be danger from lachrymal and conjunctival trouble, which must be carefully looked for and attended to. After apparent healing, these is sometimes a recurrence of the abrasion. most frequent occurrence is that the patient wakes up in the morning with great pain in the eye, and on examination, the epithelium is found partly detached and raised in the form of a blister. If Bowman's membrane is penetrated, a nebula or leucoma will result. There may also be abscess of cornea with hypcpion, and further iritis and panophthalmitis.

In punctured wounds may occur the same complications as in abrasions, and, in addition, the iris and lens may be injured. Possibly, but rarely, the uveal tract is affected.

Penetrating wounds bear, in addition to the above mentioned complications, the risk of prolapse of iris, escape of fluid with lessening of tension, and consequently possible escape of lens and vitreous, intraocular hæmorrhage, and great danger to the uveal tract.

Lacerated wounds generally involve the whole of the globe, all the risks of penetrating wounds are present in a greater degree, and the removal of the eyeball is often necessary. The importance of the position of the wound varies with its nature. In the case of superficial wounds the most unfavourable position is in the pupillary region, on account of the possibly resulting clouding of the cornea. For, if keratitis ensues, a nebula is almost certain, and if Bowman's membrane is injured, quite certain. A foreign body, if not removed immediately, causes a small inflammatory zone, and leaves a permanent, if minute, nebula. In those whose trades expose them to this kind of injury, one often finds the cornea speckled with tiny nebulæ. A nebula almost invisible to the observer may cause a great defect in the vision, on account of the dispersion of the light rays. On the other hand, a dense leucoma, leaving part of the pupil free, will not impair the sight as much as would appear. In punctured, penetrating, and lacerated wounds, the most dangerous position is that of the corneo-scleral junction. involving the uveal tract.

As to prognosis. The prognosis, in the case of abrasions and superficial foreign bodies, in the absence of conjunctival and lachrymal duct disease, especially the latter, or where these can be kept under control, is good when proper treatment is resorted to. In the case of punctured wounds. the chief danger lies in the possible