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ciil,-tr,i,rea, and to the second sounds over the second inter-cartilaginous spaces. 3. The pulmonary sound (in the secondleft interspace) has a very limited extension-viz., hardly anytowards the right, very little upwards, and very little out-wards, but it extends a varying distance downwards, gene-rally blending with the aortic sound, as in m AP and Map.4. The aortic sound, culminating in the second right inter-space, has a very wide area of extension, being loudly beard 1over the upper part of the sternum and over the cartilagesdown to the third space, except over the small area of thepulmonary sounds. It is loudly conducted to the apex. It isvery distinctly heard over tbegreater part of the right ventricle.It is heard above and for some distance to the right and tothe left of the praecordium, as displayed in the diagram.5. The ventricular area is divided by a vertical line, almostcoinciding with the parasternal line, but not identical insituation in all subjects, into a trricnspid-sownd area anda rn,itrcL-sou7aa area. Thus a portion of the right ventricleserves to conduct the mitral sound. 6. The mitral sound isheard loudly to the left of the said line over the fifth, fourth,and part of the third spaces, but less loudly and mixed with thetricuspid sound over an intermediate area to the right of thevertical line. 7. A short horizontal line, extending from thecurved extremity of the vertical line outwards along the leftthird interspace, marks off the upper boundary of loudness ofthe mitral sound. The first sound, as heard at the right andleft second spaces, is probably chiefly mitral, but perhapscompounded of mitral and tricuspid elements. 8. The tri-

cuspid is the only systolic sound heard over the lower half ofthe sternum and to the right thereof. It is also heard to theleft of the sternum as far the line of demarcation ; but in theneighbourhood of this line it is blended (in varying degreeand over a zone varying in width in different individuals) withthe mitral sound. 9. At the sternal end of the third left

space the systolic sound and the diastolic sound are bothloud over a limited area, which may be termed the" auscul-tatory valve site." The loud systolic sound heard here is inthe normal state probably mitral, and the diastolic soundis probably aortic ; but it is possible that the other two heartsounds may participate in their production.

am conscious that I have given you a very incompletesketch of the local varieties of heart sounds which comeunder the stethoscope in normal chests. Any further analysiswould probably be very difficult to carry out and it mustremain the business of each observer to obtain by con-

stant practice an empirical knowledge of what the heartsounds should be at the various regions. Without this pre-paration he would be imperfectly fitted for the next step incaidiac study-viz, the investigation of the local abnor-malities of the heart sounds. This is a yet more difficultsubject, the discussion of which I must defer to a futurelecture. The chief contradiction between generally acceptedviews and those which I have expressed relates to the con-duction of the second sounds : the sound heard over the rightventricular area being, I contend, not the pulmonary but theaortic sound. In an important monograph on the Deter-mination of the Intensity of the Heart Sounds " (Tiibingen,1885), Hermann Vierordt points out (amongst other remark-a,ble facts, a discussion of which I cannot undertake inthis place) a disparity which he is at a loss to explainbetween the intensity of the second sound at the pulmonaryinterspace (left second space) and that of the second soundat the light fifth chondro-sternal joint. Since the conclusionsstated above had been arrived at independently before I hadany knowledge of H. Vierordt’s observations, they acquirefrom the latter an indirect support, whilst they also seemto supply the explanation which he has sought.

SOUTHSEA CONVALESCENT HOME.—The Con-valescent Home for Children at Southsea has signalised thecompletion of its fifteenth year of useful work by removal toa. larger house, which has been purchased by the munificenceof the I-Ion. Mrs. North. It is capable of accommodatingtwenty patients. The annual meeting was held last weekunder the presidency of Sir Wm. King, when it was announcedthat the committee had determined to appropriate two bedsfor the use of the Royal Portsmouth Hospital. In thankingthe committee for this liberal gift, Mr. Rundle spoke of con-valescent homes as most useful adjuncts to the large hos-pitals Averaging three weeks for each visit, the hospitalwould be able to send seventeen patients for each bed duringthe year, and he had no doubt that these beds would be con-stantly occupied by a succession of suitable cases.

AddressON

CHOLERA FROM AN URBANPOINT OF VIEW.

Delivered before the Society of Medical Officers of Healthon May 15th, 1893,

BY G. A. HERON, M.D., D.P.H. GLAS.,F.R.C.P. LOND.,

PHYSICIAN TO THE CITY OF LONDON HOSPITAL FOR DISEASES OF THECHEST.

" CHOLERA from an Urban Point of View" were the wordsof the text furnished to me by the secretary of your Society,when he did me the honour to ask me to read a paper here

this evening. By "Cholera from an Urban Point of View," Iunderstand is meant the dealing with that disease after it hasbroken through the line of defence formed against it by ourport sanitary authorities. The disease, following its usualcourse, then attacks one person here and another there ; andthe first question asked concerning these scattered cases is,Are they, or are they not, cases of cholera ? Now, it is

obvious to everyone who has a clear understanding of theimportance of dealing promptly with all suspicious cases

occurring in cholera times, that these scattered cases, whichprecede practically every epidemic, ought to be immediatelyplaced under responsible medical supervision and forthwithsurrounded by every precaution tending to prevent the pos-sible spread from them of the infective principle of cholera.In order that this may be well done there must be within easyreach of the patient an official medical man, whose address canbe speedily ascertained, and who would either himself attendto the case or send some competent person to do so. The

police should, of course, make it their business to know howto direct people to such official medical addresses. It is alsocertain, that no one man could properly discharge the officialduties for a whole district without sufficient trustworthyassistance. This, I suggest, could be secured by enrollingfor this special purpose the senior students of our medicalschools and young graduates in medicine who might careto volunteer for the service. They should now-before weare even threatened with cholera-receive special instruc-tion in those duties which may fall to them, possibly in thenear future. Thus there would be ensured an efficient staffof medical officers to meet the needs of the kingdom. I

purposely omit any reference to the details of this proposedspecial course of instruction. It should certainly only be givenby men who are competent to teach it. We are still dealingwith scattered and suspicious cases occurring in cholera times,and we are supposing that such cases are surrounded promptlyby all possible precautions against the spread from them ofinfective material. Now one of the first questions which

. will confront the medical man, be he old or young, who finds

. himself in attendance on such a case, is : Is this, or is it not,a case of cholera ? It is impossible in these sporadic cases,

; if we judge of them only from the symptoms of the patientsas they lie in bed, to decide whether we have to deal with

} what is called British cholera (cholera nostras) or withL cholera proper. So far as clinical symptoms are concerned,

they throw no certain light whatever on the diagnosis of

: these early and sporadic cases. I emphasise this pointbecause I venture to think that its truth and its importanceare not sufficiently recognised, for it is only whilst these scat-tered cases alone exist in a city that we are justified, withour present knowledge, in regarding the disease as still, to avery great extent, under our control ; and if we fail to stopthe spread of infection from these sporadic cases we let loosein our midst an infection which, as the history of cholera shows.often causes an outburst of the disease before which we arewell-nigh helpless. Happily we can ascertain with certaintywhat is the real nature of these sporadic cases, for by anexamination of the dejecta of the patient and the finding thereof Koch’s comma bacillus they are stamped at once as cases ofcholera. It is only in cases of cholera that this bacterium isfound. The continental experience of last year’s epidemic hasshown us that a practised bacteriologist who has special experi-ence and skill in the examination of cholera can within a few

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minutes, with the aid of the microscope alone, diagnose thepresence of cholera in nearly one half of all cases. Especiallys this true at the beginning of an epidemic, because the first.cases are, as a rule, markedly typical in character. The,other cases require from twelve to twenty-four hours for theirdiagnosis, which can only be made with the help of cultiva-tions of bacteria taken from cholera dejecta and grown on’plates of peptonised gelatine. Only in exceptional cases areseveral days necessary in order to obtain a reliable diagnosis.As I have already dealt fully with the bacteriology of cholerain a paper which I had the honour to read before this Society- on Nov. 20th, 1885, and as the paper is published in yourTransactions for that year, I will not now go further into-this subject. As it is by means of bacteriological exami-nation alone that we can ascertain with certainty of thesesporadic cases whether they are or are not due to cholera,I therefore suggest that part of the national equipment for’the emergencies of cholera times should be a staff of efficientbacteriologists. When it is known that these sporadic cases:are caused by cholera, and as soon as this fact is made

public, there begins an exodus from the stricken city of

people who are able to leave home and who dread infection.There is also the usual traffic common to all towns. Referring- again to the continental exoerience of cholera during last

year, we tind that wherever sporadic cases appeared, even indistricts far apart from one another, their origin could be dis-tinctly traced to a cholera-infected centre, most frequently toHamburg. This fact, it seems to me, makes it in the highest’degree desirable that medical men called to persons who havelately come from a cholera-infected district and who aresuffering from any bowel derangement, no matter how trivial- it may seem to be, should make it a rule of practice to regardsuch cases as probably due to cholera. I would suggest thatin times of danger from cholera the laws which regulate thenotification of diseases should be most rigidly enforced in- all suspicious cases until they are authoritatively declared- mot to be caused by cholera The "tramp" populationis peculiarly deserving of careful attention in all times of- epidemic disease. When cholera is prevalent here, or sus-

pected to be a likely visitor to this country, I think itwould be only fair to the rest of the community to place our"tramps

" under strict medical supervision ; for it is certainthat these unfortunate people, whilst they are suffering frominfectious disease, often travel from place to place. In the

!beginning of a cholera visitation it is highly probable that our"tramps

" would provide examples of the sporadic cases to’which I have alluded ; and if this should turn out to be true- it is not easy to exaggerate the danger to the communitywhich might spring from this source. Therefore "tramps "- should be prevented from journeying about the country, unlessthey are known on medical authority to be in good health.When cholera becomes epidemic in a town cases of illnessmultiply with tremendous rapidity, and from a half to two-thirds of those attacked make up the death-rate due to the- disease. This is the common story of the early part of an’epidemic. Cholera is eminently a disease of the poor, andtherefore most of the sufferers from it should be conveyed, aspromptly as possible, to a hospital. This could be well done

hy the hand ambulance service now used by the Metro-

politan Asylums Board. These ambulances are furnished-with efficient protection against the escape from themof the dejecta of the patient. They should, of course, havefixed stations, and the police on duty would direct any-one inquiring for it to the nearest ambulance station. Ihad an interview with one of the chiefs at Scotland Yardabout this matter, and he authorised me to say that the helpof the police could be easily secured, in the directions I haverindicated, if a formal application were made for it to ScotlandYard. It is maintained by some that the moving of a cholerapatient over any considerable distance-say a mile-addsgreatly to the gravity of his condition, and may even kill’him. I have not been able to find on what data this state-- ment is made. We all admit that the quieter a cholera’patient is kept the better for him, and to this end we shape’our treatment of him so far as is consistent first of all, andbefore all, with the safety of the community, and, secondly,with a view to his own well-being. I submit that the safetyof the community demands the removal to hospital of thosewho cannot be efficiently treated in their own homes, andthe judge of the efficiency of the treatment, in the cases ofthe rich as well as of the poor, should be a properly qualified’medical man.The next point is, How shall we provide our patients with

adequate hospital accommodation ? The inquiries of the

Metropolitan Asylums Board made last year with a view topossible cholera emergencies resulted in ascertaining thatconsiderably less than 3000 beds could then have been placedat the disposal of the Board for the accommodation of cholerapatients. One of the chief officials of the Board told me that,under great pressure, it is possible, but not likely, that 3500beds might be devoted to this purpose in London. It is

hardly necessary to say that, were cholera to fall upon Londonas it did upon Hamburg the other day, even 3500 beds wouldbe but of little use in helping us to cope with such a cata-strophe ; and we must remember that these presumablyavailable beds are scattered all over London-numerous insome districts, very few in others. Moreover, it is not certainthat the incidence of cholera would accommodate itself to thenumber of beds in this or that locality. To build hospitalaccommodation for the victims of a great epidemic, wouldbe an extremely costly process. Besides, cholera bursts sud-denly into a country, and there is not time, in suchan event, to build hospitals. There seem to me but two

ways out of the difficulty. They are : to make choleracamps in the parks and other suitable open spaces of atown, and, where a town happens to be near a navigableriver, to moor old ships in the stream and use them as floatingcholera hospitals. These plans are both old. Were theyadopted, there would be practically no limit to the accommo-dation which could be provided at a very few days’ notice.As a matter of course these proposals would be objected toby not a few people. The objections, so far as I know them,rest chiefly upon the danger which it is supposed would arisefrom the spread of infection from the camps and ships.Cholera is a disease of the intestinal canal, and its infectiveproperties are found in the bowel discharges. Therefore ifwe can destroy these infective properties there is no reason-able ground for fearing the spread of infection. The excreta,having been thoroughly disinfected by some approved method,should, in the camps, be buried in deep trenches, dug everymorning and evening for the purpose. In the ships, afterdisinfection has been carried out in the same way, theexcreta should be put into suitable covered metal receptaclesand boiled for, say, an hour and then thrown into the river.In these ways, in camp and ship, the infective properties ofcholera would be rendered harmless. This being so, theobjections to these two ways of providing hospital accommoda-tion for cholera patients are practically reduced to matters ofsentiment. Against such objections facts and arguments areof practically no avail. We can but hope that common sensewill not be overwhelmed bv sentiment.As regards the important questions of how to feed a large

number of people in these camps and ships and of providingfor them adequate laundry arrangements, this could be done,I believe, without much practical difficulty. I laid these matters

very fully before Mr. P. Cremieu-Javal, and he very kindly wentinto them, as far as present data would allow of that beingdone. The feeding of patients and their attendants could,Mr. Cremieu-Javal assured me, be carried out practically at amoment’s notice, and so could the laundry arrangements, pro-vided that movable ovens and a small steam-engine for laundrypurposes were at hand and ready for use. The ovens andsteam-engine could be obtained from our Army Medical Depart-ment, where such things are always available, and in consider-able numbers, for use in military camps. Were the authoritiesto refuse to supply these things the provisioning and laundryarrangements could not be carried out under less than amonth’s notice. The cost of all this cannot now be estimated,because it must always depend upon the state of the labourmarket and upon the wages that would be demanded forworking in these cholera camps and ships.The contamination of water by cholera deiecta is the means

by which cholera spreads itself amongst men. Therefore, nowater should be used for any purpose whatever unless it hasbeen previously and quite recently boiled for at least half anhour. This rule should be strictly observed in cholera timeswhen we wash. when we brush our teeth, as well as when wecook our food or drink water. In short, water that has notbeen recently boiled should never be used for any householdor personal purpose.

Without properly trained nurses in sufficient numbers it wouldbe impossible to efficiently cope with cholera emergencies. Inthe all-important work of carrying out, under medical super-vision, the treatment of sporadic cases, and in seeing thatdisinfection of the patients and of their surroundings isthoroughly ensured, trained nurses must occupy a most impor-tant position. Without their intelligent help, disinfection, thesafeguard of the healthy, could not be carried out, and treat-

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ment, the hope of the sick, would be an impossibility. Ibelieve that nursing, in order that it may meet the require-ments of a great epidemic, can only be well done by havinga central office to which all nurses willing to serve in choleratimes could send their names and from which a supply ofnurses could be promptly obtained for towns or districtsrequiring their services. As this scheme has been broughtprominently forward by Her Royal Highness the PrincessChristian of Schleswig-Holstein and is now being carriedout in detail by the Royal British Nurses’ Association underthe supervision of Her Royal Highness, those who wish toobtain full information about this important part of the

subject can obtain it by applying to the Secretary at the officeof the Association, 8, Oxford-circus-avenue, W.

Immediately after death occurs from cholera the rectumshould be packed with some suitable substance soaked in asaturated solution of corrosive sublimate, and the graveclothes and coffin furniture should be treated in the same

way. When we become more civilised the bodies of thosewho are killed by cholera will be cremated. Meanwhile, inorder to meet the prejudices of the civilisation of to-day, themajority of those who die of plagues, which spread amongstus only by infection, must be buried.

ABSTRACT OF A

Clinical LectureON THE

CAUSES OF FAILURE IN THE TREATMENTOF SEVERE CLUB-FOOT.

Delivered at the National Orthopædic Hospital, GreatPortland-street, on May 11th, 1893,

BY F. R. FISHER, F.R.C.S. ENG.,SENIOR SURGEON TO THE NATIONAL ORTHOPÆDIC HOSPITAL AND

SURGICAL AID SOCIETY.

CONGENITAL CLUB-FOOT or talipes varus may be of a severetype even in the new-born child, but I intend to pass over thetime of infancy because, whatever may be the nature of thedistortion during the first days of life, it will certainlyincrease in severity as age advances ; especially so after thetime that the foot is used for supporting the weight of thebody. The condition at birth will during the first year or soof infancy have some influence on the degree of distortion.Thus a varus foot in a subject two years old may be moresevere than that of another who is three years of age, theformer having been in a condition of greater distortion atbirth. In a comparatively short time-say when the onechild is four and the other five years old-the state of dis-

tortion will be about the same in each case, because the

weight of the body on a deformed foot has such effectthat a slight case is very soon converted into a severe

one. So far as age is concerned we may take it that

congenital varus will in all cases, if not interfered with,have entered on the severe stage by the time the subject isfour years old. A varus foot when the distortion is fullydeveloped is a somewhat complicated piece of abnormality.The deformity consists of structural changes within the footitself and of a disturbance of the normal position of the footupon the leg. The former consists of rotation, inversion anddepression of the parts in front of the great transverse tarsaljoint upon the os calcis and astragalus. The axis of displace-ment is not central, but lies towards the inner border, so that thedisplacement of the scaphoid bone from the astragalus is muchgreater than the shifting of the cuboid from the os calcis. This

part of the deformity is originated by contraction of thetibialis muscles. The alteration in position of the foot uponthe leg is derived mainly from contraction of the gastro-cnemius and soleus, which muscles raise the heel and deprivethe foot of the movement of flexion. Orthop&aelig;dic treatmentconsists in the employment of three therapeutic measures-viz., (1) subcutaneous section of those contracted tissues whichretain the displaced foot, or any part of the foot, in anabnormal position ; (2) the use of mechanical appliances ; and<-3) physiological measures, so called, which consist chiefly

of manipulative exercises either of a mild or forciblecharacter. To these three methods I consider that ortho--

p&aelig;dic practice should be strictly limited and any departurefrom them must be regarded as not pertaining to thibranch of surgery. For instance, if in dividing contractedtissues a wound be made which is appreciably larger than thepuncture of an ordinary tenotome, then the operation can nclonger be described as subcutaneous. Also any forcible andimmediate reduction of the deformity by means of mechanicalappliances I should regard as being unorthodox. Under.stand me that I do not imply that these or other measures oftreatment are not to be recommended, but merely explairthat they are not included in the methods I have selected formy subject. The system of orthopaedic treatment, as apartfrom the methods, is to overcome one by one the differentdisplacements which contribute to the formation of a varusfoot. Thus the foot itself is restored to shape before it isbrought to its normal position on the leg; still further, thereshaping of the foot is proceeded with by first removing theinversion of the parts in front of the transverse tarsal jointand then correcting the rotation before reducing the state ofdepression. In employing these methods and in adoptingthis system the aim of the surgeon is to restore the foot asnearly as may be to the normal shape and condition and atthe same time to inflict the least possible amount of injuryupon its constituent parts. Failure may attend his efforts,and the cause of such failure I will now endeavour to explaitto you by bringing before you cases illustrating my subject.As to the operative measures a frequent cause of failure

results from the structure aimed at being incompletely dividedor missed altogether. These mishaps not infrequently occur-the former when the tendo Achillis and the latter when thetendon of the tibialis posticus muscle is the object of attack.In both instances the trouble is probably due to fear ofwounding the posterior tibial artery. The close apposition ofthese tendons to the artery has been made a great deal toomuch of. It is true that in the dead subject, with its flaccidmuscles and normal anatomy, the structures are pretty closeto one another ; but in the limb bearing a varus foot thetendon is in a state of tension and is drawn sufficiently faraway from the vessel to enable tenotomy to be performed with-out any danger. The tendon of the tibialis anticus muscle is.so easily reached that it seldom causes trouble to the operator;,occasionally, however, with the tendon of the tibialis posticus,it is purposely left untouched. This departure from theregular rule of orthopaedic surgery is almost certain to causea return of the deformity. By mechanical means, when thefoot is kept entirely at rest, considerable lengthening of themuscles can be obtained, with consequent relaxing of thetendons ; but directly the subject begins to use the limbrecontraction occurs, the foot again becomes slightly invertedand rotated, and, once these displacements are started,the deformity returns to as severe a stage as before. Thestructure which most frequently requires operation is the

plantar fascia; about this there is not much difficulty sofar as performing the operation goes, but want of care

in the after-treatment is abundantly productive of mis-

chief ; indeed, the real difficulty with all subcutaneousoperations begins after the section is completed. Thio,

apparent "bull" brings us to the most important part of oursubject. Perhaps no more successful method of promotingthe failure of orthopaedic procedure could have been devisedthan that of bringing the distortion to as good a position as,can be obtained immediately after performing tenotomy. Bythis practice no good can possibly be done, whilst a very greatdeal of evil may be originated. Consider what happens aftersubcutaneous section of any tissue if the parts be put on thestretch; a space must be created which will be filled upin some way. If the operation has been so cleverly performedthat nothing but the contracted structure has been divided,then the surrounding cellular tissue will come between theseparated parts. Such dexterity in operating is but seldomachieved ; a small vein will very probably be wounded and’extravasation of blood between the ends of the tendonor fascia and into the surrounding cellular tissue will takeplace. With this state of things repair commences, whentendon, bloodclot, cellular tissue and skin become, as it were,glued together ; then instead of a freely movable tendon youhave an indurated mass of superfluous material, which, tostill further frustrate the curative efforts of the practitioner,assumes all the characteristics of a contracting cicatrix thattends to hold the distorted parts in their misplaced positior.with even greater force than the original tissue which wa&

divided. Should the internal plantar artery be divided when