149OBJECTS OF SURGICAL ART

emphasis, and very many readers of the BritishMedical Journal must have looked forward to

acquiring this series of articles in a more permanentform. The reader’s most immediate reaction will

probably be one of horror when he considers theamount of money wasted by the prescription ofendocrine preparations by mouth which are com-

pletely inactive thus given. If the only functionof the book were to bring this home to the medicalprofession it would serve, a useful purpose; but italso provides definite guidance towards rationalendocrine therapy, and gives cause for optimism tothe most cynical.

TUBERCULOSIS IN INDIA

THE April number of the Indian Medical Gazette isdevoted to tuberculosis. In an editorial article it is

pointed out that the disease is by no means a recentarrival in India, but one that has claimed victims formany centuries (25 at least, it is believed). To-day,however, it appears to be spreading rapidly and hasbecome a problem of public rather than individualhealth. The claim is made that the soil on whichthe tubercle bacillus is implanted in India is entirelydifferent from that anywhere else in the world, thoughthis claim is somewhat modified later on. A set ofenvironmental factors of importance in the Westare not necessarily of equal importance in the East,and a public demand for sanatoriums and dispensaries,and all the paraphernalia of Western anti-tuberculosismeasures, though well meaning, is not necessarilywell advised. The alternatives are not clear, but aplea is made for organised search, both in the fieldand in the laboratory, for the best methods of com-bating the disease, and the signed articles in thisspecial number form a useful contribution to the

subject. Dr. A. C. Ukil states that tuberculosis is notyet notifiable in the rural areas of India, whilst theregistration of deaths is sufficiently defective for

many fatal cases of the disease to pass unrecognised.Public health work is therefore beset with difficulties.Nevertheless, the results of sanatorium treatment,recorded in another paper by Dr. Fremodt-Moller, atthe Union Mission Sanatorium, show that good resultsare obtainable with modern methods in India just asin Europe. Other contributions, too, give evidenceof alertness in the modern treatment of the disease.

THE TIME-RELATIONS OF CARDIAC

ENLARGEMENT

RADIOGRAPHY is useful both to establish thepresence of heart disease and to reveal its cause.

Studies to this end have been concerned more

with statics than dynamics and the changing appear-ances in the course of cardiac disorders are notwell known. Dr. Palmer,’- however, has now suc-ceeded in collecting data on the progressive changesin the heart’s size over long periods in a variety ofconditions. According to current belief, enlargementdepends chiefly on two factors-first, the work thatthe heart is called upon to do, and secondly, itscapacity for doing it. The capacity to perform workis affected by many different kinds of injury to themyocardium, especially ischaemia and chronic inflam-mation ; but apart from these a hypertrophiedmyocardium seems to become fatigued and inefficientin a way not well understood. There are probablyother factors that contribute to enlargement, andDr. Palmer suggests that age is one of them ; for a

1 Palmer, J. H., Development of Cardiac Enlargement inDisease of the Heart: a Radiological Study ; Spec. Rep. Ser.med. Res. Coun. No. 222. H.M. Stationery Office. Pp. 48. 1s.

given disorder more readily produces enlargementin the young than in the old. Congestive failureis attended by some increase in the heart’s size

(though the increase is more apparent than real), andthis is a consequence largely of changes in the auricles.On the other hand, no evidence is forthcoming insupport of " acute dilatation," which still awaits

radiological proof. Dr. Palmer, however, drawsattention to rapid local increase in the size of the leftventricle, which, if it occurs within a few monthsand without distinct aggravation of symptoms, meanscardiac aneurysm. It is to be noted that an increasein the cardiac shadow is referred to as enlargementsimply, and no attempt is made to distinguishbetween hypertrophy and dilatation. This is inaccordance with opinion nowadays held that thereis no such thing as acute enlargement and that themagnitude of the two components of enlargementare hard to assess. Though there are considerablelocal enlargements which are obvious exceptions tothis rule, differentiation, when attempted, is usuallybased more on inference from the history and

symptoms than on the physical signs. Dr. Palmer’sreport throws light on a neglected aspect of cardiology,and at the same time shows where further workshould be done.

OBJECTS OF SURGICAL ART

THE museum of the Royal College of Surgeonscontains a great many surgical instruments, and oflate years the honorary curator of the historicalcollection has endeavoured to preserve, as a memorialto eminent surgeons, specimens of instruments whichthey originated and which are known by their names.To the collections thus gathered has now been addeda number of the instruments invented and used bythe late Lord Moynihan, which have been presentedby his son. Another important addition to thissection are examples of many interesting patterns ofinstruments and appliances made by the firm ofDown Bros. over a quarter of a century ago. Mostof these are now becoming obsolete, for (as the donorpoints out) very few instruments now remain

unchanged for twenty-five years. This large assem-blage also serves to show the gradual obsolescence ofcertain operations and affords material for study bysurgeons who are proposing to design new instruments.By the kindness of Dr. R. J. Probyn Williams, thealready fine collection illustrating the history ofanaesthetic apparatus has been enlarged by a numberof pieces dating from 1895 to 1908. The includethe original model made for Paterson’s nasal gas .,

apparatus and the original model of the ether inhalerdevised by the donor.The history of the head-saw has now been worked

out by the honorary curator and the result is shownin a series of these instruments, now mounted, docu-mented, and chronologically arranged in the instru-ment room. The earliest representation of thehead-saw is that figured in a manuscript of theeleventh century by Albucasis. In the fourteenth

century there is a drawing of one in the MS. ofWilliam of Parma that belonged to John Wryghtsonof Oxford, from which a model has been made. Inthe sixteenth century Andreas Della Croce depictsseveral with blades of varied shape. After theseventeenth, the head-saw went out of use, until itsemployment was revived by Cockell about 1783.Cockell devised several instruments with different

shaped blades and six of those he originally used areincluded in the collection. In 1803 the use of thehead-saw was again advocated by William Hey,