Columbia Winihtx^ii^ 
 in t^t €itv of ileto gorfe 
 
 College of l^ftpiiciani anb ^urseonsi 
 
 Bt. dialler P. famess 
 
FLATULENCE 
 
 AND 
 
 SHOCK 
 
 BY 
 
 F. G. CROOKSHANK, M.D. Lond., M.R.C.P. 
 
 PHYSICIAN (OUT-PATIENTS), HAMPSTEAD GENERAL AND N.-W. LOND. HOSPITAL ; ASST. PHYSICIAN, 
 THE BELGRAVE HOSPITAL FOR CHILDREN, S.W. 
 
 PAUL B. HOEBER 
 
 6g, EAST 59TH STREET 
 
 NEW YORK 
 
 1913 
 
 Printed in England] 
 
PREFACE 
 
 I HAVE been asked that these two papers should be printed, 
 rather, I suspect, for the sake of the bibhography — such as it 
 is — than for any other reason. Still, I confess to surprise 
 at the interest that has been evoked, and have been almost 
 startled at the really large number of isolated facts, bearing 
 on the subjects discussed, that have been brought to one's 
 notice. Thus Dr. Spilsbury, who tells me that he has not 
 always found the coeliac axis degenerate when there has been 
 pretty widespread arterio-sclerosis, says that nevertheless in 
 such cases there is often marked hypertrophy of the muscular 
 coat of the vessel. The relevancy of this point to the sugges- 
 tion of spasm and excessive adrenalism is obvious. In respect 
 of the second paper, during discussion both Sir John Tweedy 
 and Dr. F. J. Smith narrated some cases that were very 
 a propos, and I have heard since of many others. Mr. Roland 
 Burrows, himself a lawyer, raised the interesting point 
 whether indeed the neurasthenia of twentieth-century males 
 may not be a consequence of " repression," and whether the 
 emotional displays of our eighteenth-century heroes and 
 statesmen — ^who lived in shocking times — may not have been 
 physiologically justified. Such suggestions give an even wider 
 significance to the Freudian doctrines. 
 
 The comments of the anaesthetists are very interesting. 
 
 The declaration by not a few that " surgical shock " is 
 very often a matter of overdeep anaesthesia seems based on 
 sound clinical observation, and should be correlated with 
 Verwom's masterly elucidation of the phenomena of narcosis. 
 
 Again, it is impossible to ignore the theoretical importance 
 of the marked success that Dr. H. M. Page and others have 
 enjoyed with the prolonged administration of nitrous oxide 
 
vi PREFACE 
 
 gas and oxygen. It has been suggested that this method of 
 producing anaesthesia not only avoids the paralyzing effect 
 on the oxygen-carriers, postulated by Verwom, but has 
 something to do with checking the loss of carbonic acid gas, 
 which, whether by the lungs or from the open abdomen, is 
 the essential factor in the production of acapnia. 
 
 Certainly Embley, whose paper in the Australian Medical 
 Journal, for August 17, 1912, deserves careful study, 
 recognizes respiratory depression under anaesthesia as con- 
 nected with loss of carbonic acid gas. He finds shock to be 
 less when nitrous oxide and oxygen are given with ether by 
 the closed method than otherwise ; and commends the 
 therapeutic administration of carbonic acid gas itself when 
 the respiration is depressed under chloroform or open ether. 
 
 In the Lancet for October 26, 1912, there is given, on p. 1167, 
 an account of a case of " intestinal obstruction, the result of 
 abdominal injury," in which, at the necropsy, no relevant 
 lesion was found. There are also valuable references to 
 Nothnagel's Encyclopaedia, and to a case reported by Drs. 
 Kempe and Browne, wherein the early meteorism and con- 
 stipation passed off, to return later and necessitate laparotomy. 
 In the same issue of the Lancet there is a letter from Dr. 
 Donald Hood, which is deeply interesting. Dr. Hood insists 
 that we are apt to overlook the fact that, in many cases, the 
 maximum effect of arterial disease is purely local. 
 
 F. G. C. 
 
 53, Welbeck Street, W. 
 October, 19 12. 
 
FLATULENCE* 
 
 There is a line in Horace which has been translated, though 
 with doubtful accuracy, " It is difficult to speak with propriety 
 of common things." Jack Wilkes, as all who care for Boswell 
 know, illustrated this notion by referring to the embarrass- 
 ment of a poet laureate who should describe her most Gracious 
 Majesty Queen Caroline as engaged in washing teacups. 
 Alike, too, was the difficulty which tradition in Mortlake tells 
 us was felt by a worthy local physician, called to attend that 
 august lady, when in residence at Kew and suffering from 
 what charwomen call the " windy spasms." How to devise 
 a signature to his prescription, at once respectful to his 
 sovereign and yet likely to be understood by the local apothe- 
 cary, gave him pause. It is said that in the upshot the appro- 
 priate carminative draught was ordered to be taken " quum 
 Regina habet ventum." This may not be true ; but I have 
 some diffidence in commending the vulgar subject of flatulence 
 to you. Yet it is one of great practical importance and no 
 little theoretical interest. Occasion is not always adequately 
 met by the perfunctory exhibition of Mist. Carminativa ; and, 
 though in Casualty one may be able successfully to fob off a 
 vexatious patient, yet, in private practice, one who is suffering 
 torments has little satisfaction if his doctor deems him a 
 neurotic nuisance, and, like Dogberry, thanks God when rid 
 of a pestOent knave. 
 
 Should we ask point-blank whence comes the gas eructated 
 in flatulence; or distending the abdomen in cases of meteorism, 
 the answer usually is, " From fermentation." If we press, it 
 may be admitted that, certainly, there are also some " neu- 
 rotic " cases. But to label the condition of one in distress 
 either " neurotic " or " functional " does not carry us far ; 
 
 * A paper read before the Medical Society of St. Mary's Hospital, 
 London, October 23, 1912. 
 
 7 
 
8 FLATULENCE 
 
 and so others take refuge in saying that the gas is really 
 swallowed air, though surgeons who have experience of ileus 
 Imow full well that this will not do. They, as a rule, frankly 
 admit that there is at work some influence that has not yet 
 been " precised." 
 
 Physicians are somewhat less candid. 
 
 In cases of chronic gastric dilatation without organic ob- 
 struction at the pylorus, there is, of course, a definite forma- 
 tion of lactic and butyric acids, with evolution of carbonic 
 acid and hydrogen. It is accepted that these processes are 
 the result of microbic fermentation, and also that, when yeast 
 is present, the alcoholic and acetic fermentations may proceed 
 with like evolution of gas. It is also seemingly true that, 
 when certain articles of food have been ingested, sulphuretted 
 hydrogen is produced in the bowels, or more rarely in the 
 stomach ; and that when leguminous foods containing much 
 cellulose have been eaten, marsh gas and hydrogen are evolved 
 on a quite extensive scale. 
 
 As you know, those who concern themselves with the dis- 
 orders of children have lately been at pains to distinguish 
 between the putrefactive and the fermentative organisms, 
 associating the former with decomposition of proteid food* 
 and the latter with that of carbohydrates ; recognizing, more- 
 over, the putrefactive process as inhibitory of the fermenta- 
 tive. So that one has to be a little careful in the use of words. 
 But, speaking broadly, we admit a group of cases in which 
 there is production of gas in the stomach and bowels as a 
 result of disintegrative processes due to microbic activity. 
 Sometimes there is gross error in diet ; sometimes there is 
 special importation of special organisms ; but in any case an 
 atonic condition of the digestive organs is present, and con- 
 siderable delay in the passage of food from the stomach, so 
 that the organ becomes dilated. There is a vicious circle ; 
 atony and deficient juices favour fermentation ; gas produc- 
 tion distends the stomach and sets up dilatation. And the 
 gas that is eructated is. as the patient will say, neither odour- 
 less nor flavourless. It may even be inflammable. 
 
 But there are the cases, not so easily disposed of, where 
 neither yeast nor the Bacillus butyricus occurs in the stomach 
 contents, and, rather curiously, even lactic acid is not always 
 present. Such cases fall into two groups : one called " neu- 
 rotic," with which I am most concerned ; and another, that 
 
FLATULENCE 9 
 
 I will call " dietetic." In the first the gas is almost always 
 odourless and flavourless ; in the second the odour or flavour 
 is that of the food that has been taken. In neither is there 
 odour or flavour suggestive of fermentative or putrefactive 
 bye-products. How many of us, normally eupeptic, do not 
 sometimes suffer after a meal, perhaps a little more hearty 
 than usual, and into which certain articles of diet have entered 
 disparately, from some temporary distension and eructation^ 
 that does not recur if the cause of offence be avoided ? Is it 
 credible that such flatulence is due to a special microbic infec- 
 tion, and fermentation of the stomach contents ? Of course, 
 if dietetic irregularities continue, if the stomach begin to 
 weaken, if the teeth be carious and the gums suppurate, a 
 bacterial decomposition may be superimposed ; but I speak 
 of the ordinary flatulence that occurs when potatoes, peas, 
 or beans are taken in relative excess, and which may be dis- 
 posed of by a single belch. What is the source of the gas ? 
 Not bacterial activity ; for there is no culture that will produce 
 any volume of gas in the course of half an hour. Indeed, 
 ordinary stomach contents may be kept for hours in vitro 
 before gas formation takes place. It is likely that the mech- 
 anism which is at work in purely " neurotic " cases has some- 
 thing here also to do, though not preponderatingly ; but I wish 
 to point out that, just as cases in the first group are admittedly 
 benefited by antiseptics and by mineral acids, though not 
 relieved by the administration of alkalies, so those in this 
 " dietetic " group are not notably helped by antiseptics as 
 such — are certainly not helped, as a rule, by acids and pepsin — 
 but are relieved by the administration of alkalies after meals. 
 They are sometimes called " acid dyspepsias." But you do 
 not find butyric acid in the stomach contents, although you 
 feel you ought to ; and, indeed, one is almost inclined to say 
 that some of these cases of acid dyspepsia are so called rather 
 because they are reheved by post-prandial alkalies than for 
 any other reason. It has seemed to me that these occasional 
 flatulences following dietetic indiscretion are connected, not 
 with actual hypersecretion of hydrochloric acid, but rather 
 with what one may call " relative hyperchlorhydria." That is 
 to say, the normal combination of the hydrochloric acid with 
 the albumin does not occur ; and an interesting point is that 
 Hoppe-Seyler long ago declared the evolution of hydrogen 
 and of marsh gas from food containing cellulose to be aug- 
 
10 FLATULENCE 
 
 merited by the presence of hydrochloric acid, the very sub- 
 stance that is lacking in the fermentations of chronically 
 dilated stomachs. At any rate, it seems, from the purely 
 clinical point of view, that in these occasional flatulencies 
 which are not simply neurotic, and which are, with equal 
 certainty, not due to the B. hutyricus — which are relieved 
 by post-prandial alkalies, and which may be " cured " by 
 attention to diet — there is some derangement of the normal 
 mechanism of digestion that is not yet manifest. I would 
 suggest that opportunity be taken to examine carefully the 
 stomach contents, both gaseous and liquid, in some of these 
 cases of " dietetic flatulence " that, at the risk of repetition, 
 I say do not fall either into the purely neurotic category or 
 in that where there is definite dilatation and retention. It is 
 possible that the explanation is chemical rather than bacterio- 
 logical ; perhaps enzymosis is involved. 
 
 Concerning the complex group of flatulencies in which the 
 " neurotic " or " nervous " element is generally admitted, the 
 experience of physicians seems curiously unequal. Yet one 
 clinical value they have in common : they are not appre- 
 ciably relieved by alkalies, or always by dieting. Antiseptics 
 and lavage are seldom of avail. 
 
 Some cases are in the old, others in the young ; some in 
 sober men, others in silly girls ; some of the patients are nor- 
 mally eupeptic, others habitually dyspeptic ; a few of them 
 have organic disease, others are sound. Some cases occur 
 after shock, others after operation, or during convalescence 
 from acute specifics, and, very curiously, not a few during 
 pneumonia. Many either have, or afterwards develop, acute 
 duodenal or pyloric ulcer. 
 
 Sometimes there is great distension of the abdomen, and 
 death ensues. But the common denominator is eructation, or, 
 as some would say, the seeming eructation of odourless and 
 flavourless gas. The first attack may be sudden and of great 
 violence. Sometimes there is a spell that lasts for a day or 
 two, but without return. Sometimes the eructation or quasi- 
 eructation continues, almost without intermission, for days 
 at a time. Sometimes it is periodic or recurrent. Sometimes 
 it is associated with migraine. Sometimes it follows an 
 accident, or may be reckoned a part of traumatic neuras- 
 thenia. Sometimes it seems to stand in relationship with 
 tea or tobacco. Sometimes it follows " mental shock." 
 
FLATULENCE ii 
 
 And, though I do not wish to spend time on the cases 
 of meteorism and tympanites that are seen in surgical 
 wards, it is obvious that there is an intimate relation 
 between gas in the bowels and gas in the stomach. Indeed, 
 the amazing thing is that this " neurotic flatulence," or these 
 forms of neurotic flatulence (if I may use the phrase without 
 begging any question), occur under so many different circum- 
 stances that probably none but those whose experience has 
 been promiscuous appreciate its significance. It is only thus 
 I can explain the diverse views held by those whose experience, 
 great in particular directions, has yet been curiously restricted 
 in others. Those who have once lost a patient by death, after 
 a hasty diagnosis of " air- swallowing," are a little chary of 
 prognosis ever after. Those who have themselves suffered 
 (and to them I extend my sincere sympathy) know how diffi- 
 cult it is to obtain really helpful advice. The subject stands 
 in need of elucidation, and there are two ways in which we 
 may attack it. One is to group cases according to their clinical 
 associations ; the other, to clarify our notions as to the sources 
 of the gas that distends the stomach, or is eructated, or seem- 
 ingly eructated, and then to connote our conclusions with 
 the various clinical associations. Now, of the two kinds of 
 explanation put forward, one suggests that the gas is produced 
 in the stomach (or bowels) ; the other, that only air is swal- 
 lowed or spuriously eructated. To me it seems that there is 
 some force in both explanations — that they are not necessarily 
 and always opposed. 
 
 You will agree that when, to take an extreme case, a fasting 
 person drinks a cup of tea, and within a few minutes is in 
 such distress from abdominal swelling that he loosens his 
 clothes and pants for breath, while eructation sets in and 
 continues for hours, all notion of microbic fermentation must 
 be discarded. Nor can sudden fermentation explain the 
 belching of gas that may terminate a bout of angina pectoris. 
 I do not say that mixed cases never occur, but for the moment 
 we must set the microbic fermentations on one side. So, too, 
 must we set on one side the dietetic flatulencies relieved by 
 alkalies, in which some chemical process may be at work. We 
 must concentrate on those in which the so-called " nervous " 
 spasmodic, hysterical, paralytic, or emotional element pre- 
 dominates. 
 
 It does not follow, because we dismiss both the microbic 
 
12 FLATULENCE 
 
 and the chemical hypotheses, that we are bound to fall back 
 on the notion that the eructated gas is either air that has been 
 swallowed, or only seemingly swallowed. We have an alter- 
 native : that the gas is produced in the stomach, but by a 
 process of actual secretion. This is the doctrine of pneimia- 
 tosis : unfashionable nowadays, though old. The classic 
 reference is in that lecture on dyspepsia wherein Graves tells 
 us how, in 1823, he read an essay before the King and Queen's 
 College of Physicians, in which he pointed out the " true 
 source of the acidity and flatulence observed in dyspepsia, 
 and proved, contrary to the accepted opinions, that it was the 
 result of a morbid secretion." In fact, he says : " I showed 
 that the stomach has the power, when in health, of secreting 
 acids and air, essentially necessary for the solution of the 
 alimentary mass, and proved that, in dyspepsia, this power is 
 morbidly deranged in such a manner as to give rise to a super- 
 secretion of acids and air." 
 
 It must be acknowledged that, though Graves believed the 
 normal and effective acidity of the stomach to be due to 
 lactic acid (and not to hydrochloric, as now af&rmed), he 
 clearly recognized what we did not till lately know — that 
 many gastric disorders are due to hypersecretion of the 
 normal acid of the gastric juice. I hesitate to hint it, but 
 are we quite certain that the traces of lactic acid sometimes 
 found in the contents of healthy stomachs are no indication 
 that lactic acid may be an accessory factor in normal diges- 
 tion ? The absence of lactic acid in hyperchlorhydria 
 rather suggests that we ought not always to look on lactic 
 acid as a morbid constituent of stomach contents, like pus 
 or blood. At any rate, we all know that sour milk may be 
 a very present help in time of hyperchlorhydria. This is, 
 however, a digression. 
 
 Trousseau adopted Graves's theory of pneumatosis. He 
 said : " Flatulent dyspepsia is characterized by the secre- 
 tion in excessive quantity of the gases which are normally 
 developed in the intestinal canal. Immediately after the 
 ingestion of food these gases are produced, more or less 
 abundantly, in the stomach and intestines, which they dis- 
 tend ; and this distension leads to such increase in size of 
 the abdomen as obliges the patients to loosen their clothes. 
 An attempt has been made to explain this phenomenon by 
 supposing that there takes place a rapid fermentation of the 
 
FLATULENCE 13 
 
 ingested feculent substances ; that there is a production of 
 carbonic acid gas, the result of a fermentation in the intestinal 
 digestive canal exactly similar to that which occurs in a wine- 
 maker's mash-tub. Matters do not, however, proceed after 
 that fashion. As Graves remarked, persons subject to flatu- 
 lence have gas developed in the intestinal canal with almost 
 equal rapidity, whether they eat food that they can ferment 
 or whether they confine themselves to almost exclusively 
 animal aliment. In the latter case, one cannot say that there 
 has been fermentation. That some gas is always produced 
 from the alimentary mass during digestion is, however, a fact 
 which is certain ; but the principal source of the gas is secre- 
 tion from the alimentary canal. A proof that this secretion 
 is independent of the coction of the elements is afforded by 
 the fact that an hysterical woman will sometimes become 
 tjmipanitic in ten minutes. Under our very eyes and hands 
 we see and feel the abdomen attain a great size. Consequently 
 the formation of gas is the result of disturbance of the nervous 
 system, an increased secretion taking place in exactly the 
 same way that there is, under similar influence, an increased 
 secretion of tears, saliva, or urine." 
 
 Furthermore, " this flatulence may occur when the stomach 
 is empty," and " while measures prescribed on the fermenta- 
 tion notion are useless, baths, cold effusions, and ether are 
 all useful." 
 
 If one may speak with any disrespect of such giants as 
 Graves and Trousseau, it is obvious that, whatever we think 
 of the notion of gas secretion, both attempted to prove too 
 much. Yet it is interesting to note that by implication 
 Trousseau recognized three kinds of cases in which flatulence 
 may arise — those in which there is fermentation, those in 
 which there is excessive gas-forming during " coction," and 
 the " nervous " or " secretory " cases. Trousseau's first 
 group corresponds to that in which we now admit microbic 
 fermentation. The cases of excessive gas formation during 
 coction may be identified with those I have called " dietetic "; 
 the third group is that which I have called " nervous." 
 
 It is interesting to note, by the way, that Grayson has 
 suggested recently that gas is, as Trousseau and Graves 
 believed, produced normally during digestion. 
 
 But the epoch that succeeded Trousseau's was a materiaHstic 
 one : it was that of the great German chemists and biologists 
 
14 FLATULENCE 
 
 — of Liebig and of others — and the notion of normal or ab- 
 normal secretion of gas under nervous influences was dropped. 
 Well, the great era of " fermentation," and, later, of bacterial 
 action, set in ; and if any poor clinician hinted that there were 
 patients whose cases were not thus to be explained, he was 
 told that such were wretched hysterics. As time went on, 
 however, it was felt by a few that this attitude of Podsnappery 
 was hardly just, and the doctrine of aerophagy was revived. 
 Now, the doctrine of aerophagy lays it down that the disten- 
 sion is due to air that has been swallowed, and is eructated 
 on occasion ; or, in the alternative, as the lawyers say, that 
 there is no distension, and the air is not really swallowed, but 
 is gulped backwards and forN^^ards in the throat. Of this doc- 
 trine Dr. WyUie of Edinburgh is an able exponent, and a dis- 
 cussion of his views is imperative. But for myself, I do assert 
 that there is, in a good many cases, actual pneumatosis, or 
 secretion of gas from the stomach. That the practice of aero- 
 phagy in some form or another exists is true, but sometimes 
 it is a habit induced by the presence of gas in the stomach, 
 and sometimes it is purely mimetic. In explaining this phe- 
 nomenon of flatulence we have not to pin our faith to fer- 
 mentation, or to gas secretion, or to aerophagy as a suf&cient 
 explanation of aU cases, but to distinguish the degrees in 
 which each of these processes may obtain. Yet, just as 
 Graves went to one extreme in ascribing all flatulencies to 
 secretion, and the great chemists went to the other in saying 
 all worth notice are due to fermentation, so Dr. Wyllie goes 
 too far in suggesting that, whenever air swallowing or gulping 
 occurs, no gas is being produced in the stomach. 
 
 Some may think the notion of air secretion fantastic ; but 
 let us see on what basis it may rest before we consider Dr. 
 Wyllie's views. 
 
 My interest in the subject dates back to conversations of 
 years ago with Dr. Muir Evans, of Lowestoft, who used to 
 express his disbelief that cases of sudden tympanitic disten- 
 sion could be due to either fermentation or to air swallowing. 
 He has made some valuable investigations, to which I will 
 presently refer ; but what has chiefly struck me is his reference, 
 in support of the idea that gas can be secreted from the 
 stomach wall, to the swimming-bladder of fishes. Now, this 
 point cuts the ground from beneath the feet of those hard- 
 headed persons who, a priori, deny the possibility of gas 
 
FLATULENCE 15 
 
 secretion. Gas exchange is, of course, admittedly physio- 
 logical. Now, although in some fishes the swimming-bladder 
 is used as a lung, in many of the Teleostei its function is that 
 of a float ; and it is provided with a mechanism whereby gas 
 is produced by secretion, and not by mere diffusion. This 
 secretion of gas has been shown by experiment to be controlled 
 by branches of the vagus and sympathetic nerves "in an 
 exactly similar fashion to the secretion of saliva in a sali- 
 vary gland." Moreover, the swimming-bladder, whether 
 homologous with the lung, as some believe, or not, arises in 
 Teleostei as a diverticulum of the gut wall, and is supplied with 
 blood, not from the aortic arches, but from branches of the 
 dorsal aorta. Its blood-supply, then — and the point is not 
 without relevance — corresponds with that of the human 
 stomach. 
 
 It might be thought that the question whether the eructa- 
 tions of " neurotic " patients are secreted gas or swallowed 
 air could be immediately settled by analysis. But this is not 
 so, for the gaseous contents of what may be thought a normal 
 stomach are equivalent to atmospheric air in which the oxygen 
 is entirely replaced by carbonic acid ; so that even those who, 
 like Dr. Wyllie, hesitate to admit that in health or disease the 
 stomach wall can secrete gas, are compelled to acknowledge 
 that at any rate the stomach can exchange carbonic acid for 
 oxygen. Dr. Evans, who has made many analyses, maintains 
 that some of the nitrogen in normal stomach gas, as well as 
 in nervous eructations, is given off from the blood, and that 
 some of the carbonic acid may be secreted otherwise than in 
 mere exchange. He has certainly shown that we have no 
 right to assume that the nitrogen is derived directly from the 
 air, since, in the sound of the codfish, this gas occurs in the 
 proportion of 85 per cent, or so by volume, without any ques- 
 tion of its production otherwise than by secretion. I am not 
 concerned to labour the details of gas analysis, for since Dr. 
 Hutchison admits that the hypothesis of gas secretion from 
 the stomach is not disproven, and I can find no other that is 
 adequate, I am inclined to think that the weight of evidence is 
 in its favour. The ultimate mechanism of this gas secretion 
 is another point on which two American physicians — Drs. 
 Woodgate and Graham — have, I believe, done some experi- 
 mental work, though I have not, as yet, been able to obtain 
 any complete account. But, before passing to this and a 
 
i6 FLATULENCE 
 
 consideration of the doctrines of aerophagy, some brief cita- 
 tions from current textbooks that will serve to show the 
 dearth of leading that we have on the subject may not be 
 without interest. 
 
 Sir William Osier does not discuss the general significance 
 of flatulence, but, using the words " nervous eructations " 
 and " aerophagia " as synonymous, says that the " hysterical 
 nature of the affection is sometimes testified to by the occur- 
 rence of several cases in a household." Surely one might as 
 well say that epilepsy or chorea is hysterical because mimetic 
 cases occur in a household. But he goes on to declare : " The 
 expelled gas in these cases is atmospheric air, swallowed or 
 aspirated from without. Sometimes the whole process may 
 be clearly observed, but in other instances the act of swallowing 
 may he almost or quite imperceptible." 
 
 Sir Lauder Brunton exhibits all the resource of the Scots 
 minister who, when confronted with a difficult text, looked 
 it boldly in the face, and passed on. He does, however, say 
 that sometimes a little air is swallowed with food. 
 
 Sir Clifford Allbutt toys gracefully, as is his wont, with 
 the topic, and exhibits all his literary charm and command 
 of peregrinate phraseology. But he is a little elusive. He 
 admits that with tremendous gusts of wind there may be no 
 obvious distension ; he seems to agree that there may be — at 
 least, in hysterical subjects — some source of wind other than 
 decomposition of food. He says it is possible that wind may 
 be poured into the alimentary canal from its own walls. But 
 he will neither aver nor deny that this may be an explanation 
 of the strange phenomena sometimes occurring " when a hard- 
 working and sensible professional man will wake in the small 
 hours and belch forth wind boisterously for hours." That 
 hard case has been my own, and I confess I find it unsatisfying 
 when Sir Clifford goes on to say that " though the flatulence 
 may have associated with it disturbance of the heart, to 
 follow this symptom beyond its mechanical causes would 
 lead us into a general discussion of hysteria and neuras- 
 thenia." 
 
 A most pregnant suggestion, and for which I am thankful : 
 but an odd excuse, surely ! 
 
 Dr. Soltau Fenwick comes a little to grips. He says very 
 little is known concerning the escape of gases from blood in 
 the walls of the stomach, but he admits it to be a sound 
 
FLATULENCE 17 
 
 clinical observation that quantities of carbonic acid gas are 
 often expelled from a stomach that is devoid of food ; and he 
 states, without comment, that the contents removed from 
 the stomach of a healthy person exhibit no signs of gas forma- 
 tion for at least twenty-four hours. 
 
 Dr. Frederick Taylor judiciously says that flatulence some- 
 times develops so speedily that its explanation on chemical 
 grounds is difficult, and even its association with neurosis does 
 not always make its mechanism clear. 
 
 What, now, have the professed aerophagists to say ? 
 
 Dr. Wyllie, their protagonist, after giving a luminous account 
 of that flatulence, arising from the fermentation of food, 
 which he calls " true gastric flatulence," goes on to speak of 
 that which is false — which, in other words, he believes to be 
 only the eructation of atmospheric air that is either actually 
 expelled from the stomach (after having been introduced into 
 it in one or other of certain ways), or that is only seemingly 
 so expelled. He makes allusion to the classical " secretory " 
 theory, and admits that the normal stomach has the power of 
 exchanging carbonic acid gas for the oxygen of intaken air ; 
 he also alludes to the possible production of gas from the 
 stomach walls in cases of failing heart with pulmonary con- 
 gestion, as if by a kind of vicarious respiratory process. 
 Moreover, he says it is best, for the moment, to consider the 
 question of the secretion of gas from the stomach under 
 nervous influences an open one. But he clearly does not be- 
 lieve in it ; and he seeks throughout his paper to establish the 
 predominant influence of two elements — hysteria and habit. 
 His observations are most acute, certainly ; but he takes no 
 notice of the hard-working, and I hope sensible, professional 
 men like myself, who give Sir Clifford AUbutt such uneasy 
 qualms, and who have an unfortunate habit of dying just after 
 they have been told they are neurotic. Nor does he take any 
 heed of the flatulency in angina pectoris, and of those deaths 
 that are ascribed to that cliche of the coroner's court — pressure 
 of the stomach on a fatty heart. He does not explain the case 
 of ileus or that of volvulus ; but he distinguishes three varieties 
 of false flatulence — air gulping, air swallowing, and air suction. 
 
 Air gulping is a process by which air is introduced into the 
 oesophagus by application of the tongue-tip to the teeth, as 
 in pronouncing the letter T, the cavity of the mouth and 
 pharynx being filled with air from the larynx, while shut off 
 
i8 FLATULENCE 
 
 from the nares by elevation of the palate, and from the larynx 
 by closure of the glottis. Dr. Wyllie says that the air, while 
 thus shut off, is put under strong and sudden compression by 
 elevation of the larynx and the dorsum of the tongue, and 
 under this pressure is forced into the oesophagus, entering 
 with a slight noise. The subject then, making a slight expira- 
 tory effort with the glottis closed, puts pressure on the oeso- 
 phagus, and expels air with a slight sound of eructation. Or, 
 if he choose, he can go on gulping the air till so much is intro- 
 duced into the oesophagus that it finds its way into the 
 stomach. The process can be repeated, and it then seems as 
 if long-continued eructations from the stomach are going on. 
 This process I have recognized clearly in myself and in others. 
 But one point Dr. Wyllie overlooks : the air in the mouth and 
 pharynx is shut off from the oesophagus by spasm or hyper- 
 tonus at the junction of the pharynx and oesophagus. This 
 must indeed be so, else " strong compression " would not be 
 needed to drive the air into the oesophagus ; a simple 
 swallowing movement would suffice. 
 
 Now, Dr. Wyllie thinks that quite a number of cases of 
 flatulence can be explained away by degrading them to the 
 level of habit actions of this nature. I do not deny that 
 some of the neuro-mimetic cases may be thus explained, nor 
 that, if the subject of gas production in the stomach contracts 
 the habit of air gulping, he may continue it, just as a neurotic 
 child who learns eye-twitching because of conjunctival irrita- 
 tion may continue it as a tic long after the primary source of 
 irritation has been cured. But most air gulpers contract the 
 habit because it enables them, by overcoming oesophageal 
 spasm, to eructate gas imprisoned in the stomach. Air 
 gulping is, primarily, a semi-purposive action designed to 
 overcome involuntary spasm either at the pharyngeal or 
 the cardiac end of the oesophagus, or both. 
 
 True air swallowing, however, apart from the swallowing 
 of inconsiderable quantities of air with food, is another affair. 
 It is performed, like ordinary swallowing, by the aid of a 
 wave of contraction from the dorsum of the tongue backwards, 
 and is not opposed by oesophageal spasm. Though babies 
 brought up by hand may suck in air through their bottles, 
 and hand-reared calves are said by veterinarians to become 
 " hoven " in like manner, it is rather a rare accomplishment, 
 like wagging one's ears, and not really relevant to the present 
 
FLATULENCE 19 
 
 discussion. But there is another form of air swallowing, as 
 Dr. Wyllie calls it, which needs analysis. When adult cattle, 
 in feeding, get portions of turnip arrested in the gullet, what 
 is known as " choldng " supervenes. The rumen becomes 
 distended with air, and, unless relief be afforded, the animal 
 speedily dies. A very usual plan of treatment is to push the 
 lump down with a probang. Now, Dr. Wyllie says that the 
 enormous distension of the rumen with gas is due to the fact 
 that the animals make convulsive efforts to swallow the lump, 
 and in so doing swallow air, which gets past the lump into the 
 rumen. This may or may not be so ; for myself, I do not see 
 how the air can get past, but Dr. Wyllie finds support for his 
 notion in the fact that some Lowland farmers treat choking 
 animals by using a gag or bit which separates the jaws, and 
 in the observation that some of these choking animals indulge 
 in a kind of eructation like that of the air gulpers. Now, a 
 great many veterinary surgeons think differently — that the 
 gas is actually produced in the stomach — and they allege 
 cogent reasons. Personally, I agree with them, but think that 
 the oesophagus becomes applied to the lump by spasm, as does 
 the urethra to a catheter, and that the convulsive swallowings 
 and gulpings are semi- purposive attempts to inhibit the spasm. 
 The putting of the bit or gag in the mouth inhibits the spasm, 
 just as does a similar procedure have similar effect when anaes- 
 thesia is being induced. It is obvious that when spasm is 
 inhibited, and proper action of the oesophagus is resumed, the 
 food can be swallowed easily. Has not each of us, when a 
 child, had a lump of food " stuck in the throat " successfully 
 coaxed on by swallowing water ? And, according to some 
 veterinary surgeons, if the rumen be cut into, letting out the 
 gas, which, as they believe, is secreted from the stomach wall 
 under nervous influences, the spasm may be overcome. 
 
 There is one other kind of " hoven " which must be men- 
 tioned : it is the case of those animals who, after feeding on 
 damp clover, get enormous distension, and die, as is so graphic- 
 ally described in " Far from the Madding Crowd." Dr. Wyllie 
 refers to this, but does not explain it, as, indeed, I do not see 
 how he can, on his air-swallowing theory. 
 
 We have now discussed air gulping and air swallowing. 
 Air suction has no accessary connection with the stomach, 
 as everyone accustomed to gynaecological work knows. When 
 a Sims' speculum is passed on a fat woman, or the vagina is 
 
20 FLATULENCE 
 
 opened, with the patient in the Trendelenburg position, air 
 rushes in with a squelch as negative pressure comes into play. 
 Barry, too, has reported cases of air entering the bladder, 
 almost audibly, in women with lax muscular tone while walk- 
 ing about. This is air suction. But in horses who are crib- 
 biters, as in some human beings, it is brought about, in respect 
 of the oesophagus, by fixation of the inspiratory muscles, 
 resulting in negative pressure which opens it, and allows air 
 to enter. Air thus introduced into the oesophagus may be 
 passed into the stomach, or " expelled with machine-like 
 regularity and a kind of sob." The trick is easily learned. 
 The jaw is thrust out, and the larynx elevated. A deep breath 
 is taken. When tension is relaxed, the air is let out with 
 " eructation." A biggish or emphysematous chest and a lax 
 tone of the involuntary muscles seem to help in the accom- 
 plishment, just as in the gynaecological analogue. Dr. Wyllie, 
 with admirable consistency, looks on air suction as a sort of 
 habit, or vice, as grooms say. But it is not always so. It 
 may be an involuntary accompaniment, in the type of person 
 I have described, of that curious physical sign of profound 
 attention noted by Ribot — the holding of the breath. At 
 other times, as in a case mentioned by Dr. Mackenzie, it seems 
 associated with such muscular effort as walking up a hill when 
 the breath is held and the mouth is opened. But, of course, 
 habit may easily be established. 
 
 The position, however, that I would take up, after some 
 curious personal experiences and the observation of a good 
 many patients, is that in flatulency we may have to deal with : 
 
 1. Disintegrating processes, due to micro bic activity. 
 
 2. Such cases as Trousseau thought due to excessive gas- 
 production during coction, and which are perhaps dietetic, 
 chemical, or enzjmiotic. 
 
 3. Gas " secretion " from the walls of the stomach or bowels. 
 
 4. Gas secretion to which air gulping is added, to overcome 
 the spasm that prevents eructation. 
 
 5. Cases in which air gulping occurs as a trick accidentally 
 learned : as a form of neuro-mimesis ; or as a manifestation of 
 hysteria, in association with globus hystericus. 
 
 6. True air swallowing, in babies fed from a defective 
 apparatus; and occasionally in adults. 
 
 7. Air suction, analogous to the suction of air into the 
 vagina or bladder, occurring in persons with hypotonus of 
 
FLATULENCE 21 
 
 involuntary muscle, and under circumstances that fix the 
 respiration. This also may be continued as a habit, possibly 
 alternative to air gulping. 
 
 It is really with the third and fourth classes only that I wish 
 now to deal, for these have points of clinical and physiological 
 importance in common, and it is they that give rise to the 
 difficulties of practice. 
 
 By great good fortune, only the other day I came across an 
 article by Mr. Begg (a veterinary surgeon who practises in 
 Lanark) dealing with " hoven " or " choking " in cattle. Mr. 
 Begg evidently believes that the gas is really produced in 
 some way or another in the rumen ; sometimes, perhaps, by 
 fermentation, and sometimes not. He does not discuss how 
 or why it should be produced ; his aim is purely clinical, or 
 stabular, as I suppose one should say. But he distinguishes 
 two types of " hoven." The one is the classical kind, where a 
 lump is impacted in the oesophagus. In this he says that the 
 gas goes on being emitted rhythmically after the obstruction 
 is removed ; and, if the obstruction cannot be at once pushed 
 down, he recommends opening the rumen — doing a gastros- 
 tomy, in fact. These points seem clearly on my side, and not 
 on Dr. Wyllie's. The other type is represented by what occurs 
 when animals have a debauch of damp aftermath of clover ; 
 then the gas is intimately mixed with the mass of fodder, and 
 is not evacuated easily by mere puncture of the rumen. 
 This seems rather to suggest " coction," or some rapid 
 enz57motic change ; but Mr. Begg goes on to remark 
 that cases conforming more or less to one or other type are 
 also apt to occur (i) when an animal has eaten poisonous 
 plants ; {2) after exposure to chill ; (3) when sudden feeding 
 follows fasting or over-driving ; (4) after taking of very cold 
 water : and, inclusively, in animals predisposed to indigestion. 
 Finally, it is laid down as a general law that the particular 
 condition of the animal may he a major factor in the presence 
 of the less potent of the recognized causes. This seems to me 
 an admirable statement that we may apply directly to human 
 beings. For so-called nervous flatulence occurs when there 
 is obstruction, or spasm after ingestion of certain foods ; as a 
 result of poisoning from tea or tobacco ; in cases of shock, 
 exhaustion, or exposure ; and in those subject to previous 
 dyspepsia. And, again, the particular condition of individuals 
 accounts for the occurrence cf very severe symptoms, when. 
 
22 FLATULENCE 
 
 apparently, only the less potent external causes may be at 
 work. If to this we add the recognition of purpose in air 
 gulping, we have very nearly covered the ground. But not 
 quite : for distressing flatulence may occur under some other 
 conditions. Before, however, alluding to these, I must return 
 for one moment to the question of oesophageal spasm in its 
 relation to air gulping. There is no need for me to adduce 
 the work of Dr. Hertz and others in proof that, with various 
 irritative and so-called functional disorders of the stomach, 
 spasm may occur at the pylorus, at the cardia, or midway 
 indeed, and also at the junction of the pharynx and oesophagus. 
 But my thesis is that, given the production of gas in the 
 stomach otherwise than from fermentation, simple or multiple 
 spasm does occur, imprisoning the poured-out gas. The 
 mechanism of the spasm is probably intimately connected 
 with the mechanism of the gas production ; but that it does 
 occur I am convinced. I once was fortunate enough to get 
 a regular air secreter and gulper examined on the screen during 
 one of his bouts. We gave him a bismuth drink — a rather 
 hazardous proceeding for those who were standing by, as he 
 was spluttering like a geyser — and I shall never forget the 
 radiologist's bewilderment as he saw, first a stricture at the 
 upper end, and then one at the lower end, of the oesophagus. 
 Of course, as the sequel proved, the strictures were spasmodic 
 only ; but the fact remains that there is spasm, that this 
 spasm prevents the eructation of the gas, and that the air 
 gulping is a device to overcome the spasm. It gives reUef, 
 but it does not necessarily stop the gas production. Hence 
 the need for repetition of the act. Should anyone have doubt 
 as to the association of spasm with eructation, I would ask 
 him to read a paper by Meunier on its occurrence in duodenal 
 ulcer. You will remember, too, how when a patient under an 
 anaesthetic is going to vomit, he first of all swallows — an auto- 
 matic device to inhibit the spasm that is keeping back the 
 food chucked against the cardia ; and you will agree with me 
 that, by manipulating the jaw, it may be possible to stop the 
 threatened vomiting. But opening the mouth assists vomi- 
 tion, just as does Dr. Wyllie's use of the gag, which he has 
 borrowed from the farmers and applied to human beings, 
 inhibit spasm even better than the gulping which it supplants. 
 Dr. Guthrie Rankin was very near the truth when speaking 
 recently of the wretched people with neurotic dyspepsia who 
 
FLATULENCE 23 
 
 indulge in air swallowing and so forth to obtain fancied relief 
 from their sufferings. But one might, with equal wit, speak 
 of the wretched neurotics who, when deep under ether and 
 inclined to vomit, persist in swallowing, as if that could do 
 them any good ; or the foolish persons who, when so ill-advised 
 as to have acute perforative peritonitis, insist on contracting 
 down their recti on the intestines — an habit most annoying 
 to the surgeon in attendance, and quite futile if intended as 
 any real protection to the leak. 
 
 Setting on one side the mimetic cases, and admitting that in 
 others air gulping is only secondary, it remains for us to con- 
 sider the clinical aspects of pneumatosis itself in greater detail. 
 
 It is not unseldom found, when a patient comes for advice, 
 that the first attack was a violent and very distressing one, 
 and that subsequent attacks have been less severe, though 
 more prolonged. And, as Sir Clifford Allbutt has pointed out, 
 often they disturb the patient at night, and persist during the 
 small hours. Another feature is the not infrequent alteration 
 of other secretory functions : sometimes little urine is passed, 
 even for days, yet when the attack subsides there may be an 
 abundant flux of limpid fluid, as after hystero- epilepsy and 
 angina pectoris. Two noteworthy sources of distress are 
 cardiac irregularities and dyspnoea. It is usual to explain 
 the cardiac irregularity or embarrassment as due to pressure 
 of the distended stomach on the heart. No doubt this has 
 its importance, but it is a mistake invariably to attribute 
 death, when it occurs, to this cause alone. For I would remind 
 you that death does occur in these cases ; even Dr. Wyllie 
 describes one fatal event, wherein the stomach was so dis- 
 tended with gas that the peritoneum was actually cracked. 
 He expresses himself as frankly puzzled by such an ending to 
 what he believed to be a simple affair of air gulping. But I 
 have seen several such, and on the occasion of my own first 
 attack was for some little time in a very distressed condition. 
 
 Another source of cardiac distress is imprisonment in the 
 oesophagus of gas escaped from the stomach. In this event, 
 until the spasm relaxes, permitting eructation, the patient 
 may be very uncomfortable and look very queer, the pulse 
 becoming very irregular. In quite a number of cases of recur- 
 rent flatulence of this nature there is arrhythmia from ven- 
 tricular extra-systole. In the absence of organic change in 
 the cardiac apparatus, it seems fair to regard the arrhythmai 
 
24 FLATULENCE 
 
 as cin expression of the underlying neurosis, and not as a mere 
 consequence of the gastric distension ; it is certainly the truth 
 that these cases are usual!}- toxic ones, in which tea and 
 tobacco play their part. 
 
 Again, there are cases in which both the flatulence and the 
 cardiac affection seem to form part of what Sir Wilham Gowers 
 has called a " vaso- vagal " attack. In such, in mj^ own ex- 
 perience, there is often a tendency to bradycardia. 
 
 For nearly twelve years I have known a gentleman who, 
 now over eighty, is. for his age, one of the most ^ngorous 
 men, physicallj^ and mentallj^ that I have met. His pulse 
 has been, for the last twenty or thirty years, getting slower 
 and slower. Without any heart-block whatsoever, it now 
 beats normally about fifty times a minute. But, especially 
 when he has been subjected to any annoyance, or has been 
 exhausted in the prosecution of the public duties that he still 
 performs, he gets appaUing bouts of gas production, and his 
 pulse falls even to forty per minute, although perfectly regular. 
 In support of the notion that this is due to vagal neurosis, I 
 may mention that about six years ago, when convalescent from 
 a basal pneumonia, this gentleman had hiccough which lasted 
 for two days \\ithout intermission. 
 
 Yet, again, there are cases in which there is actual cardiac 
 disease associated \^ith flatulence. To one group Dr. WyUe 
 has referred — that of persons with faiUng compensation to 
 mitral disorder — but a ver\- important class is formed by those 
 who have angina pectoris, or sometimes what is known as 
 " angina abdominis." Other patients have aortic disease. 
 
 The significance of flatulence is, in these conditions, con- 
 siderable. You will recollect the case of the late Premier, 
 who, one night after making a long speech, was seized, 
 according to the Press, with an attack of flatulent indigestion ; 
 but he died of heart disease a few months later. 
 
 Still, by a sort of reciprocating arrangement between the 
 heart and stomach, true angina pectoris may be precipitated 
 by gastric irritation ; and patients who are the subject of 
 veritable angina pectoris may have minor seizures induced 
 through indiscretions in diet, in alternation with purely cardio- 
 pathic ones. And, this being so, it is not surprising to meet 
 with such cases as narrated by Dr. Mackenzie, of people with 
 classical heart-block, whose attacks are associated with 
 pneumatosis. 
 
FLATULENCE 25 
 
 Some neurasthenic patients with flatulence have false 
 angina. These are toxic cases, as a rule, where tea and tobacco 
 have their part. And I would remind you that tea and 
 tobacco may be taken in moderation for years, and yet, quite 
 suddenly, if the patient come under stress, will begin to exert 
 so marked a toxic influence that the cause of the symptoms 
 may escape recognition because the excess is so purely rela- 
 tive. Even so with cattle ; the particular state of the beast 
 allows a less potent cause to produce exaggerated effects. 
 
 The vaso- vagal cases must be connoted with those flatu- 
 lencies that occur, in spite of careful feeding, during pneu- 
 monia ; in which connection I would refer to papers by Mr. 
 Turner and by Dr. Neuhof . And there are the cases that occur 
 during convalescence from acute specific diseases, on which 
 Dr. Campbell Thomson has made some shrewd remarks. We 
 have not yet exhausted the possibilities. There are cases asso- 
 ciated with precedent gastric disorder ; and there are those 
 into which the element of shock or exhaustion enters. To 
 take the last first, I would remind you that, as Mr. Armour 
 has shown, flatulent distension and eructation is a common 
 manifestation in traumatic neurasthenia. But it has relation 
 to trauma apart from neurasthenia, as is demonstrated by 
 the occurrence of post-operative tjntnpany, and such cases 
 as that of a steady, sober, healthy gentleman who fell into 
 a brook one night, picked himself up, went home, and died 
 in a fortnight of "flatulent dyspepsia," with no lesion that 
 was discoverable at the post-mortem. Such a case has a 
 peculiar bearing on the question of shock, but it must suffice 
 to say here that the element of shock cannot well be 
 separated entirely from the fact that, just as the overdriven 
 and chilled cattle most easily get hoven, so it is harassed, 
 overworked professional men, as well as silly tea-drinking 
 girls, who suffer from flatulence with which there is asso- 
 ciated no cardiac or vascular disease. 
 
 Still, in human beings, as in cattle, it is from an harassed 
 stomach, and especially from one which is subjected to ir- 
 regular meals and to meals when exhausted, that gas produc- 
 tion is to be expected. Even a telephonic summons may 
 precipitate an effusion of gas when a tired man is at the table ; 
 mental agitation and annoyance have their share, and so do 
 certain kinds of food. At the same time, some of the worst 
 spells I have ever seen, and, moreover, quite uncontrolled by 
 
26 FLATULENCE 
 
 washing out or by antiseptics, have been in association with 
 malignant disease in or about the stomach. In all these the 
 vagus plays its part. But the most fascinating connotation 
 is with acute duodenal ulcer. The American surgeons (notably 
 Starr) admit that, if we delve into the past history of him with 
 duodenal or pyloric ulcer, we get an account of neurotic 
 dyspepsia. And Binnie has pointed out that one factor 
 common to all cases of duodenal ulcer is vascular change. 
 
 And Dr. Herschell, while reckoning — I think wrongly — aero- 
 phagy as purely neurasthenic, yet admits that pnemnatosis 
 or gas secretion, associated with complaints of spasm in the 
 throat, does occur in close alliance with duodenal or pyloric 
 ulcer. I would say this : that quite a number of these flatu- 
 lent cases that go on for weeks at a time, that first improve 
 and then relapse, ultimately develop chronic ulcer ; and there 
 is reason to believe that very often spells of flatulence are 
 associated with the formation of an acute mucous ulcer that 
 heals up and breaks down again. Neuhof finds an intimate 
 relation between the occurrence of flatulence, the formation 
 of these acute mucous ulcers (as Starr calls them), and irrita- 
 tion of the vagus. And can we not now see dimly the relation 
 between the shock of a bum, the acute duodenal ulcers of 
 burns, and the flatulence and distension that so commonly 
 follow extensive skin burns ? I think so. 
 
 Though all subjects of pneumatosis complain, in degree, that 
 they cannot get their breath, j^et it is often noticeable that 
 there is no real dyspnoea. Indeed, in the very worst cases of 
 pneumatosis the breathing may be infrequent and shallow, 
 though for the patient the sensation of airlessness is most 
 distressing. There is, too, a peculiar restlessness in these 
 graver cases which I now recognize as equivalent to the rest- 
 lessness of shock, and of impending death in diphtheria when 
 internal respiration is abrogated. 
 
 It is not to be denied that the actual mechanical impediment 
 to respiration from an enormously dilated stomach may be 
 very great, and I do not decline to admit the intrusion of the 
 element of cardiac distress. But, on the occasion of my own 
 first and most severe attack, which occurred with almost ridicu- 
 lous suddenness during convalescence from diphtheria, the 
 sensation of air hunger was so distressing, and yet the respira- 
 tions were so slow and infrequent, that I thought my respira- 
 tory muscles were paralyzed. 
 
FLATULENCE 27 
 
 I now recognize the relation of this condition to what is 
 known as " acapnia." You will recollect that Henderson of 
 Yale has shown how there is a definite relation between shock, 
 vaso-constriction, and that condition of acapnia in which there 
 is such a diminution of carbonic acid gas in the tissues and 
 blood that the respiration is slowed until the carbonic acid 
 accumulates up to stimulating strength, and hyperpnoea or 
 dyspncea returns. I do not say that all Henderson's deduc- 
 tions will be maintained, but his observations are acute. 
 Now, it has been proved by Crile that, if abdominal viscera 
 are exposed experimentally, carbonic acid gas is given off 
 rapidly from them. And the obvious inference is that in 
 laparotomy such a loss of carbonic acid gas may occur in 
 this way that acapnia is produced, and may be a factor in 
 death under the anaesthetic ; or afterwards, as others have 
 shown. 
 
 Though Henderson thinks that acapnia is a cause of shock, 
 I am more inclined to think that it is a part of " shock," 
 especially since Crile has shown how, if the displaced viscera be 
 covered with omentum, the carbonic acid gas is not given off. 
 It is interesting to note that, in abdominal operations, Mr. 
 Arbuthnot Lane covers the bowels with a vaselined silk sheet, 
 and I have heard it said that his shock effects are remarkably 
 slight. But I ask you, if carbonic acid gas be thus given off 
 from the viscera in experiments, is it ridiculous to suggest that 
 in states of flatulency it is given off into the Imnen of the 
 viscus ? And I beg you to note this : that our veterinary 
 friend at Lanark says he believes " hoven " cattle die of 
 carbonic acid gas poisoning, and not of heart failure. Since 
 acapnia leads to all sorts of curious asphyxial consequences, 
 he is at least on the right track. Let us agree that the 
 gases of the body are seriously deranged as a result of the 
 pneumatosis, and he comes into line with us all. 
 
 Acapnia, moreover, may be produced by forced or by arti- 
 ficial respiration. So we can understand how it is that the 
 hyperpnoea, caused by the mechanical pressure of a distended 
 stomach, may help to induce acapnia and its consequences. 
 And, again, a lack of ox5^gen without excessive carbonic acid 
 in the blood sets up increased tonus of the circular muscle 
 fibres, while in acapnia the tonus is lost. I now realize how 
 it was that, when my acapnia became extreme, my spasm 
 relaxed, and up came the wind ! 
 
28 FLATULENCE 
 
 The key to the understanding of these many different condi- 
 tions is this : patients with true angina pectoris get flatulence 
 and eructations, not because their coronary arteries are 
 sclerosed, as Held has suggested, but because they have 
 sclerosis of their cceliac axis.* We do not often examine the 
 state of the branches of the coeliac axis ; but I have been pro- 
 foundly impressed by a case of my own in which the patient, 
 who had suffered for some time from angina abdominis and 
 flatulence, developed necrosis of her pancreas, and died. She 
 had a very degenerate coeliac axis, and her pancreatic artery 
 was blocked. Dr. Bernstein tells me he has seen this several 
 times. I put it to you that where there is chief incidence of the 
 disease on the coronary arteries, the case will pass as angina 
 pectoris ; where there is greater incidence on the coeliac axis, 
 the case is one of angina abdominis. The flatulence in either 
 case is connected with " intermittent claudication " of the 
 gastric arteries, just as the heart pain is due to that of the 
 coronaries. For we must admit that, in addition to the nar- 
 rowing of the coronary arteries from disease, there is super- 
 added, just as in intermittent claudication of the legs, either 
 some spasm of the non-rigid parts, or, at least, insufficiency 
 of the blood-supply for the occasion. The same sort of thing 
 occurs in the brain, as Sir William Osier has shown ; and Sir 
 Lauder Brunton has told us how, in migraine — which I remind 
 you is often associated with some degree of flatulence — there 
 is recognizable contraction of the peripheral branches of the 
 temporal artery. But migraine is, if the expression be 
 allowed, only the functional replica of the headaches of arterio- 
 sclerosis ; and a functional replica of true angina — pectoris aut 
 abdominis — is, in measure, to be found in the flatulent disturb- 
 ances that accompany migraine. I find it hard to resist the 
 conclusion that the underlying mechanism of the processes 
 that give us these wind storms is, in part at least, indicated 
 by spasm or insufficiency of the arterial vessels. If you 
 like to apply the same conclusions to ileus and to meteorism, 
 I will not disagree, although, of course, fermentation and 
 putrefaction have their share of the blame ; for Murphy and 
 Vincent have laid it down that interference with the circula- 
 tion is a vital factor in the production of ileus. Certainly 
 Stone, Bernheim, and Whipple think that some unknown 
 
 * The recent remarks of Fiessinger, and of Robin, are of great 
 interest. (Acad, de Medecine: S6ance du ler Octobre, 1912.) 
 
FLATULENCE 29 
 
 poison is at work, and it is true that the interference with the 
 circulation to which Murphy and Vincent look is that which 
 follows venous congestion. But now we seem in touch with 
 Dr. Wyllie's admission of possible gas secretion in failing mitral 
 compensation. An essential point, however, is that of 
 oxygen-carrying, and the suggestion may be hazarded that 
 the unknown toxic substance that Stone and his colleagues 
 have failed to isolate is one of those curious bodies, allied to 
 catalyse and oxidase, that Verworn has explained so luminously 
 to us, and that Strauss and Winternitz have worked with. If 
 so, we have some glimmerings of light on the ultimate mech- 
 anism of gas production, both in acapnia and in flatulence. 
 For the moment, however, it is to the fact that, in degree, in all 
 these cases there seems to be some limitation of oxygenated 
 blood-supply that I ask your attention. I will not exclude 
 even the purely hysterical cases, in which there is evolved gas, 
 and the globus hystericus. 
 
 In a recent admirable lecture by Dr. Campbell Thomson, 
 stress is laid on the " vasomotor basis," if I may use the term, 
 of neurasthenia ; and on the dissociation in neurasthenia, and 
 also in hysteria, of what I may call "vasomotor units." Janet's 
 dissociation theory of hysteria is, of course, a different matter, 
 though physical and psychical analogies are not new. And this 
 dissociation notion is but complementary to Sielig's theory of 
 irradiation. The fact is, we have so long been under the spell 
 of the cerebro-spinal neurologists that we have neglected the 
 55^1 pathetic. The idea of the autonomic nervous system, as 
 set forth by Professor Sherrington, may redress the balance. 
 Still, what we have to remember is that though in the old- 
 fashioned cerebro-spinal system there is an hierarchy, in 
 which lower centres are subordinated to upper ones, in the 
 sympathetic we have a different arrangement, reminiscent of 
 that stage in the history of the race in which there is segmenta- 
 tion, or a series of units, that are linked together, and of 
 which none is subordinate to any other. But the efficient 
 working of the autonomic system depends on such co-opera- 
 tion between the two elements as is secured at the synapses, 
 subject to efficiency of the supreme head. When the synapses 
 are disconnected, as they certainly are by nicotine, the various 
 segments, or some of them, rebel. And so there are different 
 " types " of neurasthenia — sexual, intestinal, gastric, cardiac, 
 and so forth. But, you will ask, how does this concern those 
 
30 FLATULENCE 
 
 cases in which pneumatosis is a consequence of shock, of emo- 
 tion, or of acute infectious disorders ? The autonomic nervous 
 system gives us ahnk between skin stimulation and visceral 
 effect (probably in great part a matter of the vasomotor con- 
 nections) that obtains equally as a justification for the use of 
 poultices or counter-irritation in visceral disease, and as an 
 explanation of the unhappy consequences of a winding blow 
 below the belt ; while at the same time it explains the reverse 
 effect, of visceral disease setting up superficial skin tenderness, 
 and the extraordinarily good results of Franke's operation 
 (avulsion of the intercostal nerves from the ganglia) in the 
 gastric crises of locomotor ataxy. The nature of these sensory, 
 visceral, and vasomotor connections is well explained in a 
 recent paper by Watson Wadsworth. 
 
 Another link is found in a synthesis of the work of Cannon, 
 Hoskins, Hemmeter, Meltzer, and many others, who have 
 established the importance of the adrenal machinery in shock, 
 in emotional stress, and in acute specific disorders. Their 
 work has been both simphfied and obscured by our realiza- 
 tion that the adrenals themselves are not merely a pair of 
 organs secreting a special substance, but almost an integral 
 part of the sympathetic system at any rate so far as their 
 medullary substance is concerned. Moreover, there is the as 
 yet only half-suspected importance of that wonderful series 
 of paired organs — the accessory adrenals or chromaffine 
 bodies, coterminous with the chain of sympathetic gangha. I 
 say only half-suspected ; for, though Sajous long ago hinted 
 at the function of adrenal secretion as an oxygen carrier, or, 
 at any rate, as one of the active elements in the management 
 of internal respiration, or tissue gas-exchange, it is only the 
 other day that Falta and Priestley proved that the chromaffine 
 bodies generally are active agents in the conduct of " internal 
 respiration," and Fuchs and Roth showed how injection of 
 adrenalin increases the intake of air and the output of carbonic 
 acid gas by the lungs. It is possible that we may find oxidase 
 or catalyse to take origin in these structures. Need I point 
 out to you that these chromaffine bodies are very perfectly 
 provided in those fishes that have swimming-bladders ? or 
 allude to the breathlessness, the air hunger, and the notable 
 flatulence of patients with Addison's disease, that you may 
 agree that the hypothesis of gas secretion from the stomach 
 is not foolish, and that Trousseau and Graves, our veterinary 
 
FLATULENCE 31 
 
 surgeon at Lanark, and acute practitioners like Dr. Muir Evans, 
 may now stand in line with the most eager workers in Conti- 
 nental and transatlantic laboratories ? 
 
 There is a maze of splanchnic effects and of sympathetic 
 effects ; of tonus, hypotonus, and hypertonus ; of stimulations 
 and depressions ; of inhibitions and of activations ; of oxida- 
 tions and of oxidation arrests ; of reflexes this way and that ; 
 of paralyses and spasms ; of checks and counter-checks to be 
 explained. Most puzzling of all are the diverse effects of 
 adrenalin itself. At one time we find it necessary to the main- 
 tenance of muscular tonus ; at another, that an excessive dose 
 is destructive of tone. There is the suggestion of purely local 
 action or selection, and there is Cannon's idea of sensitive 
 spots ; but perhaps the nearest approach to a solution has 
 been given by Hoskins. 
 
 The exact elucidation of the connection that undoubtedly 
 does obtain in the various cases of pneumatosis between the 
 arteries, the nervous mechanisms, and the chromaffine organs, 
 is not yet for us. That there is such a connection, and that 
 when we have it explained we shall understand both the gas 
 production and the eccentricities of muscular and arterial tonus 
 that are common to them all, I am convinced. 
 
 No doubt the chain, or vicious circle, composed of vascular, 
 nervous, and chromaffine systems, may be commenced or 
 broken at any point. In purely hysterical cases the deter- 
 mining influence is from above. In shock cases, in ileus, and 
 in those arising during diphtheria and other disorders, the 
 adrenal or chromaffine system is exhausted ; and so it is in 
 these that, as we should expect, the gas secretion is most 
 abundant, the internal respiration most affected, the acapnia 
 most obvious, and death least rare. 
 
 In neurasthenia and in the anginal conditions, true and 
 false, the effects are, as a rule, dependent on one or two of the 
 vasomotor " segments " controlled by the autonomic system. 
 In primary vaso- vagal cases, probably in the basal pneumonias, 
 and certainly in many of the dyspeptics, irritation of afferent 
 vagal fibres seems to start the ball rolling. So that the relation 
 of duodenal ulcer to flatulence is twofold. When, as in shock 
 from burns, and perhaps in other cases, acute mucous ulcer 
 and flatulence develop, we have an intensive use of the 
 mechanism that is employed when we put a mustard plaster 
 or poultice on the skin by way of counter-irritation. When 
 
32 FLATULENCE 
 
 a chronic ulcer of the duodenum or irritative ingesta set up 
 flatulent attacks with irradiating and anginal S37mptoms, the 
 " viscero- vasomotor " mechanism is primarily engaged. But 
 in each case all three elements are involved, and we should not 
 forget what Crile has called the " master key " — racial habit, 
 or phylogenetic association. We may surmise that, just as 
 the Teleostean fish, when it sinks to escape its enemies, adjusts 
 its swimming-bladder and gains a different sea-level, so do we, 
 when brought low by stress or exhaustion, unconsciously 
 protect ourselves, or component segments from aggression, by 
 the evolution of gases. Shock itself is protective ; and, in 
 fact, it is not easy to think of a single manifestation in either 
 hysteria or neurasthenia which is not more or less defensive. 
 
 Perhaps hysteria is rather defensive against injury to per- 
 sonal interests, whilst neurasthenic manifestations are protec- 
 tive to physical stresses. That is to say, in the latter case the 
 organs threatened with damage from abuse are thrown out 
 of gear by segmental dissociation. And, just so, if an hys- 
 terical woman is called on to make some self-sacrifice, she 
 finds her defence in dislocating the mechanism that should be 
 employed in the ungrateful task. 
 
 The treatment of these various flatulencies is not always 
 easy, but a few practical hints may be given. 
 
 It is clear that, when microbic fermentation is the pre- 
 dominant element in gas production, washings out, antiseptics, 
 acids and pepsin, and a diet suitable to the occasion, are 
 obviously to be prescribed. 
 
 In the great " dietetic " or " coction " group, one may have 
 greater difficulty in finding what to order or what habit to 
 correct ; but alkaHes after meals will help most. 
 
 In the complex group of flatulencies from " secreted " gas 
 these measures will hardly serve. It is obvious that an etio- 
 logical, or rather a pathological, diagnosis is required. By 
 way of immediate treatment : remember Trousseau's " cold 
 affusions and ether." Prescribe local vaso-dilators, rube- 
 facients, anti-spasm odics. " Dry" meals are best. 
 
 But, in strictest confidence, I will tell you this : should 
 any of you, from overwork, overmuch tea, overmuch tobacco, 
 or what not, get a spell of neurotic flatulence, and eructations 
 with air gulping, nothing will give you so much relief as a bottle 
 of the very best creme de menthe, sipped slowly and steadily 
 until you are better. 
 
SHOCK* 
 
 The discussion and understanding of shock, although of para- 
 mount importance to the clinician, the physiologist, and the 
 lawyer, is involved in much obscurity. Perhaps it would be 
 well to avoid, at any rate, terminological confusion by setting 
 on one side, as distinct from shock, the condition known as 
 " collapse." By " collapse " we mean that sum of bodily 
 states which is associated with loss or draining of the vital 
 fluids, as in haemorrhage or cholera. Shock remains as the 
 sum of conditions obtaining when the reaction by the 
 nervous systems to afferent impulses is incompatible with the 
 usual performance of vital functions, so that the patient may 
 die without the necessary coincidence of any obvious lesion 
 in itself inconsistent with life. But, of course, shock and 
 collapse may coexist. 
 
 We cannot hope to estimate the intensity of the afferent 
 impulses that is requisite to destroy life by shock ; for, as Mr. 
 Tyrrell Gray has said, we have to reckon with the shock value 
 of the individual. Probably this shock value is a physiological 
 " function," but there are racial values as well as individual 
 values. In great measure these depend on the state of the 
 internal secretions or their balance. Thus, the hyperthyroidal 
 Bengalee has a higher shock value than the negro, and the 
 lively Gaul is more easily perturbed than the phlegmatic 
 Teuton. 
 
 Still, the shock value of an individual varies from time to 
 time, and different parts of the body have different shock 
 values. A tap below the belt may wind a man on whose 
 thorax I could hammer without causing distress ; and there 
 are other elements — to wit, that of unpreparedness. A false 
 step in the dark may momentarily shake the nerves of a man 
 who will take the spills of a day's hunting without turning a 
 
 * A paper read before the Medico-Legal Society, October 22, 1912. 
 
 33 3 
 
34 SHOCK 
 
 hair ; and the late Mr. Dent pointed out how a policeman, 
 suddenly injured when on duty in a street brawl, will suffer 
 more severely from shock than a soldier wounded in action. 
 
 Again, the trauma may be what is called " psychical," as 
 when a piece of bad news is communicated, or there is a sudden 
 and terrifpng sight ; although there is always a physical 
 process underlying psychical impression. 
 
 When these factors are considered, it must be agreed that, 
 unless there be definite simulation, we have little justification 
 for aspersing one who complains of serious perturbations on 
 an occasion that may seem to us trivial. Many people have, 
 indeed, as we say, died of simple fright. 
 f I spoke just now of the nervous systems designedly ; for we 
 have not one, but three, nervous systems. We have the 
 ' cerebro-spinal nervous system, the S5mipathetic nervous 
 system, and also the co-ordination of parts of these two into 
 a third organization — the autonomic nervous system. If, for 
 the sake of legal members, I may hazard an illustration, I 
 would say that just so in this country we have a fairly stable 
 and organized aristocracy and a less coherent democracy ; 
 though the system on which the stability of the constitution 
 depends is that formed by the co-operation of a part of the 
 aristocracy and a part of the commonality. And, seemingly, 
 in shock the maintenance of the functional iirEegnty of the" 
 autonom ic jystem is seriously compromised. It is certainly 
 true that what doctors call " shock " (meaning thereby the 
 consequences of a shock) is, in part, a defensive reaction of 
 the autonomic nervous system against assault that has been 
 committed. 
 
 It fails of its purpose at times, no doubt, and may even be 
 too intense for the safety of the organism. But the fact 
 remains that, as Crile has pointed out, the shock mechanism 
 is one forged many generations c^go in the history of the race, 
 when some apparatus was necessary to secure instant prepara- 
 tion for flight or withdrawal on occasion of danger. 
 
 Poke a snail with a straw, and see it draw in its horns. 
 
 Such are the beginnings of the complexes of shock and of 
 traumatic neurasthenia which so admirably contribute to the 
 support of our twin professions. But just as a rifle may have 
 too light a pull, so may the shock reaction be overdone, to 
 the disadvantage of the organism. 
 
 It is perhaps somewhat unfortunate that, owing to the 
 
SHOCK 35 
 
 possibly excessive attention paid to experimental work of late 
 years, shock, to the minds of many medical men, has come to 
 mean an affair of blood- pressure curves, and what not, that 
 can be best investigated in dogs and on rabbits. And so some 
 of the shock effects that can hardly be investigated save by 
 observations on human beings have become a little dis- 
 credited, and are almost treated as if they had no existence, 
 or, at any rate, no right to be mentioned in polite professional 
 society. It is to some of these shock effects, and particularly 
 to those indicated by the term " delayed shock," once in some 
 clinical favour but now a little in the shade, that I propose 
 to refer. 
 
 If we have to state the most intense form of shock, we at 
 once think of those cases of sudden death, where there is no 
 precedent disease, that are brought about by events which 
 produce no obvious lesion. Such deaths happen when there 
 is sudden immersion in water, and the individual dies without 
 having time to drown. Other examples are narrated by 
 Brouardel in his book, wherein he, following Brown-Sequard, 
 speaks of them as deaths from inhibition. Let me give you 
 an instance. 
 
 Last summer a Sikh was cycling through a London street. 
 He had a side-sHp when opposite a hospital. He was at once 
 taken in, but no injury was found save a dislocated thumb, 
 which was reduced. He turned to leave the hospital, and 
 died on the doorstep. At the post-mortem neither injury nor 
 disease was found. 
 
 When, however, shock falls short of immediate death pro- 
 duction, there may be a very serious condition lasting some 
 twenty-four hours or so, which may be terminated by death 
 or may end in gradual recovery. This is the common kind of 
 shock, from which we say people suffer after operation or 
 serious injury. 
 
 But there is a group of serious cases in which, after the 
 infliction of some traimia, the subject displays emotional 
 perturbation, rallies, seems to be doing well, and yet ultimately 
 develops symptoms which may be indifferently severe or may 
 terminate in death. 
 
 The cases from which there is recovery sometimes pass as 
 " traimiatic neurasthenia," in which, as all know, a definite 
 latent period elapses between the symptoms immediately dis- 
 played and those that " come on " later, and give us so much 
 
36 SHOCK 
 
 occasion for professional activity. The cases in which, after 
 a latent period that may be long or short, grave and even 
 fatal consequences ensue, are those to which I now refer as 
 cases of "delayed shock," using a term that is, or was, 
 consecrated by use. 
 
 Common to both traumatic neurasthenia and delayed shock 
 are unexpectedness of the trauma, and high psychical, rather 
 than physical, value of the causative incident. 
 
 The prolonged anxiety and stress of shipwreck is not so 
 effective in producing traumatic neurasthenia or delayed 
 shock as is a railway collision, or a prank played on a kitchen- 
 maid with a turnip, a clothes-prop, and a candle. 
 
 Now, it is not an unreasonable deduction that the symptoms 
 which follow the latent interval are perhaps due to the exhaus- 
 tion of certain mechanisms in combating the immediate 
 effects of the physical or psychical trauma. And, indeed, 
 years ago Mr. Fumeaux Jordan very acutely pointed out 
 that many of the immediate manifestations of what we call 
 " shock " are really efforts of the organism to combat the 
 effect of the trauma. 
 / When we have a sudden fright, if taken off our guard, we 
 turn pale. The blood is diverted from the skin, where it is 
 not needed, to the heart and lungs, so that these organs are 
 well supplied for the immediate flight prompted by our 
 ancestral origins. 
 \/ Now, the experimental work of Cannon and his associates 
 seems to prove that when animals have been subjected to 
 injury, or deliberately frightened to death, the adrenal system 
 (a part of the mechanism that manages the blood-distribution) 
 may be so completely exhausted by its efforts that it becomes 
 bankrupt, and death ensues. 
 
 In these experiments we seem to see the physiological 
 explanation of the phenomena of " delayed shock" in human 
 beings. 
 
 Cases of delayed shock are not very uncommon, but they 
 are often masked. We all know how usual it is for an aged 
 person to die a week or two after a slight fall that has involved 
 fracture of the femur. This is " delayed shock." It escapes 
 recognition as such only because there is, what sounds for- 
 midable, a fracture of the thigh. 
 
 Yet a fracture of the thigh is itself a trivial affair so far as 
 life is concerned. It is true that sometimes a low kind of 
 
SHOCK 37 
 
 pneumonia ensues, but not always ; and even when it does, 
 there is a valid explanation. At any rate, the pneumonia 
 itself is seldom so severe as necessarily to interfere with life. 
 Again, after burns, death from delayed shock is not infrequent 
 even when no vital organ has been implicated and there is 
 little sepsis. 
 
 The point that I am anxious to establish is this : that when 
 death occurs ten days or so after trauma, we should not hesi- 
 tate to ascribe death to the " accident " merely because there 
 has not been present such a totally irrelevant lesion as a frac- 
 ture of the thigh or an extensive scald. 
 
 I do not say that such deaths are very common, for obviously 
 there usually is a lesion ; but they do occur. I have met with 
 several, and have had the opportunity of inquiring into others. 
 Many have been recorded in forgotten papers ; but the modern 
 textbooks ignore them in most remarkable fashion, and even 
 so erudite a compilation as Mr. Knocker's makes no mention 
 of their happening. 
 
 Though they present, as is only natural, points of individual 
 difference, there are not a few S5miptoms from which we can 
 construct a common denominator. 
 
 There is usually immediate manifestation of some psychical 
 agitation ; but this may pass off. There is a longer or shorter 
 period in which the patient may seem to be suffering hardly at 
 all ; and there are indications of interference with the visceral 
 functions. The blood-pressure is affected, and the heart tends 
 to dilate, for it loses tone ; the urine is scanty ; the bowels 
 are obstinately constipated ; flatulence and eructations are 
 common ; and there is a good deal of shortness of breath. As 
 it may be the respiratory, the cardiac, the gastric, the intes- 
 tinal, or other symptoms, that notably attract the doctor's 
 attention, so, if death occurs, it is ascribed to congestion of 
 the lungs, to heart failure, to pressure of the stomach on 
 the heart, to stoppage of the bowels, or even to suppres- 
 sion of urine.* Sometimes the flatulence, constipation, 
 and distension are so marked that operation is proposed and 
 carried out ; but no condition is found within the surgeon's 
 ambit. 
 
 When after trauma there are continuing hysterics, the 
 
 * In a measure, the " shock mechanism " may be concerned in some 
 "obstructive" suppressions of urine. The relation of Grave's disease 
 to shock should not be forgotten. 
 
38 SHOCK 
 
 patient will probably win through with little physical damage. 
 When the early psychical disturbances have play, but are 
 controlled, traumatic neurasthenia, or the more marked type 
 of " delayed shock," may ensue. But sometimes there is no 
 initial hysteria ; the subject displays a peculiar apathy, and 
 death is pretty sure to follow. 
 You will aU remember how when — 
 
 " Home they brought her waxrior dead ; 
 She ne'er spoke nor uttered cry ; 
 All the maidens watching said : 
 ' She must weep, or she will die.' " 
 
 In such cases the autonomic nervous system is thoroughly 
 disorganized, probably by inhibition from above. 
 
 The connections at the synapses are broken, and unless 
 contact is re-estabUshed death may ensue. 
 
 The warrior's lady had her fount of tears dried up, and 
 probably she was obstinately constipated and passed no 
 water ; when her autonomic nervous system got to work 
 again not only the tears but other secretions were doubtless 
 abundantly established, with excellent results. 
 
 Mr. Clinton Dent once related how many years ago at 
 St. George's Hospital a water-tank burst through a ceiling 
 and the floor below, carrjring with it in its career a bed in 
 which was a woman convalescent from some unimportant 
 affection. This woman, in spite of her precipitate descent to 
 the lower ward, sustained no overt injury save a trifling scalp 
 wound. But she passed into a curiously apathetic condition, 
 like that exhibited by some patients who have been burnt. 
 She was seen by the late Mr. Caesar Hawkins, who said that, 
 though he could give no reason for his opinion, yet his experi- 
 ence taught him that she would die. She did die, about three 
 weeks after the accident, and at the post-mortem no lesion 
 was discovered. Mr. Page recorded the case of a girl who 
 was shaken in a railway accident. She was hysterical at the 
 time, but rallied, then took to her bed, and died, without any 
 obvious reason, in about five weeks. Sir Samuel Wilks has 
 narrated other cases of the same sort, 
 
 Mr. Turner several years ago reported the case of a man 
 who fell when crossing a railway track and broke his leg. 
 That same night he developed retention of urine, absolute 
 constipation, and abdominal distension. In two days he was 
 lying in bed "like a ball." He had no peritonitis or other 
 
SHOCK 39 
 
 indication of visceral injury. But he died on the tenth day. 
 It is true that before he died some pneumonia developed, but, 
 as Mr. Turner says in a pregnant phrase, this shows that the 
 shock had affected other organs than the bowels. 
 
 Cases of what is called " traumatic pneumonia " are not very 
 uncommon, and one — the case of Etherington — is a legal classic. 
 
 But the usual explanation given is that the accident or 
 injury in some mysterious way lowers the patient's vitality, 
 and renders him or her more susceptible to the pathogenic 
 growth in the lungs of the pneumococcus, which is, of course, 
 a very usual denizen of the mouth. This mysterious lowering 
 of vitahty seems to me a phrase which explains nothing. 
 
 It has some appearance of plausibiHty when the pneumonia 
 follows a blow on the chest, but it loses force when we consider 
 the case of a man with a broken leg ; so that it is then usual 
 to suggest that the pneumonia is hypostatic, the result of 
 congestion of the lung from confinement to bed. Mr. Turner's 
 case forces us to seek some other explanation, and his expres- 
 sion, that the pneumonia showed that the shock had affected 
 other organs than the bowels, carries us some way towards an 
 understanding. 
 
 Everyone knows that, in spite of the jeers of therapeutic 
 nihilists, a poultice or a mustard-plaster applied to the skin 
 does affect the functional state of deep-seated organs. And 
 we know that disease processes in certain organs give rise to 
 pain in correlated skin areas. Now, whereas till lately the 
 notion of what is called " counter-irritation " had been a little 
 discredited, the phenomenon, for instance, of abdominal pain 
 and tenderness in pneumonia does show us that there is 
 an active connection between the cutaneous nerves and the 
 viscera, and no longer renders it foolish to think that an active 
 poulticing may, through the nerves controlling the distribution 
 of blood to an organ, so affect the vascular state of that organ 
 as to favourably influence disease processes. 
 
 And we have physiological justification for assuming or 
 believing that, let us say, the application of cold to the skin 
 may, under certain circumstances, so affect the state of deep 
 viscera, in respect of the local circulation of blood therein, 
 as to pave the way for the establishment of an active microbic 
 inflammation. 
 
 We know, too, that normally certain skin areas are corre- 
 
40 SHOCK 
 
 lated with certain viscera for good or for evil. But we have 
 to reckon with the phenomenon of irradiation, whereby the 
 effects of an intense nerve impression spread to units of the 
 autonomic nervous system (which is, indeed, a series of seg- 
 ments or units) other than the proper one. You may in some 
 buildings see a telephone switchboard so arranged that 
 different persons can be called, or can call, independently. 
 Such is the normal arrangement of the autonomic system, 
 whereby skin areas can call up visceral areas, and vice versa. 
 But an arrangement may be made so that if a call of fire is 
 received at the office a special switch can be thrown over, 
 and the various instruments can be simultaneously rung. 
 If the operator is a fool, this is done unnecessarily. 
 
 And in shock something of this sort seems to occur ; so 
 that we can see how it is that, as in Mr. Turner's case and 
 others, a physical and psychical trauma may, given certain 
 conditions, adversely affect the vascular state not only of 
 the bowels, but the lungs. Neuhof, an American physician, 
 has lately paid particular attention to this mechanism for the 
 occasional production of pneumonia. He calls some such cases 
 of pneumonia " vagus pneumonias," for physiological reasons. 
 
 A case of great legal and medical importance came under 
 my notice a few months ago. The subject was a man well 
 known to me by repute — healthy, sober, and active. His age 
 was forty-nine. On the evening of November 14 last he 
 left the house of a friend to walk to the station. In passing 
 through the grounds he missed his way, and stepped suddenly 
 over the perpendicular bank of a brook, or ha-ha, into the 
 water below. The height of the bank above the water was 
 4 feet : the depth of the water about 2 feet 6 inches. He fell 
 on to one knee, but was not immersed, so scrambled out and 
 made his way back to the house in a state of some agitation. 
 He was, in fact, at first hysterical. However, he got home, 
 a distance of some miles, in a cab, and was seen by a doctor, 
 who found no injury save a grazed knee. The next day 
 the unfortunate gentleman went to his office as usual, but 
 complained of shortness of breath and some pain in the loins. 
 The hysteria had been controlled. 
 
 He began to suffer from what seemed to be flatulent dys- 
 pepsia ; the wind was indeed incessant ; he was obstinately 
 constipated, and passed little water. He became worse, yet 
 attended intermittently to business. On November 30, 
 
SHOCK 41 
 
 sixteen days after the accident, he died suddenly after drinking 
 a glass of water to relieve his " wind." 
 
 A claim was made on a company in which he was insured 
 on the ground that death had resulted from the accident. 
 
 A post-mortem examination was ordered : no sign of any 
 injury or surgical condition such as embolism was found. 
 But there was recent dilatation of the stomach and some 
 dilatation of the heart. Owing, however, to the undoubted 
 fact that decomposition had advanced with extreme rapidity 
 in a few hours, it was not, in the opinion of some who were 
 present, possible to be definite as to the non-existence of fatty 
 degeneration. 
 
 Therefore, the claim was disputed : apparently on the ground 
 that the deceased died from heart failure, possibly in some 
 measure due to a hypothetical precedent degeneration, but 
 certainly in the last resort determined by the " flatulent dys- 
 pepsia," if not by the drink of cold water. It was also sug- 
 gested that the flatulent dyspepsia was, together with the 
 constipation, set up by lack of exercise, consequent on the 
 slight knee injury and the rest at home. 
 
 In fine, death was not due to the accident. 
 
 At this stage my opinion was asked by the solicitor for the 
 widow, and I gave it to the effect that if there had been no 
 accident the fatal event would not have occurred — that, 
 indeed, the case was one of delayed shock. 
 
 Learned counsel was then good enough to read me the case 
 of Etherington, as illustrating the legal point that we might 
 have to meet. 
 
 This case is one of a gentleman who had a fall in the hunting- 
 field, went up to town the next day, fell ill, and presently 
 died of pneumonia. It was claimed that the pneumonia de- 
 veloped as a result of the vitality having been lowered by the 
 shock of the fall, pneumococci being present in the body at 
 the time. The claim was disputed on the ground that the 
 terms of the policy denied benefits if there should be inter- 
 vening causes between accident and death, and it was asserted 
 that the pneumonia was such an intervening cause. On 
 appeal, the Lords Justices held that the insurance company 
 were not entitled to relief if the intervening incident or cause 
 were a link in the natural chain of events or causes developed 
 between the accident and the death, inasmuch as the words 
 of the policy were to be construed as applying only to the 
 
42 SHOCK 
 
 fortuitous intervention of some other or fresh agency causing 
 death. They held that the pneumonia was no such fortuitous 
 intervention, but an incident in the natural chain of events, 
 and gave judgment against the company. In our case I 
 certainly thought that there was not the intervention of any 
 fresh agency, and so we went to arbitration. But, after 
 the hearing of \\dtnesses as to fact, an offer of compromise 
 was made and accepted, so that the question of delayed 
 shock was never submitted to the learned arbitrator, 
 
 I think you will agree with me that it is important that the 
 exact nature of cases such as these should be defined. In the 
 case of Etherington there was a definite intervening illness, 
 indicated at the post-mortem by the usual signs. Superficially 
 it might seem that here the insurance company had a good 
 case. But. apart from the luminous interpretation of the 
 words of the particular pohcy bj^ Lord Justice Williams, 
 medically they had a bad one. Only the medical witnesses 
 for the claimants might have put their case a little higher — 
 " precised it." as the French say — and, instead of speaking 
 generally of lowered vitality, drawn attention to the definite 
 mechanism that exists in the autonomic nervous system for 
 the production, in shock, of disturbance of function in special 
 viscera. In my case, however, there was no gross or organic 
 condition such as pneumonia to set up as an intervening 
 agency ; there was really no disease at all discoverable at the 
 post-mortem, and until the time of death there had been 
 no symptoms that required the assumption of what we call 
 " organic change " to render them comprehensible. It was 
 apparently because there was no more than functional disorder 
 manifested that the insurance company hesitated to meet the 
 claim. If there had been the fracture of even one bone, had 
 there been a patch of pneumonia no bigger than a crown-piece 
 that we could have sworn to, all would have been well. But 
 neither the discovery of a fracture nor the existence of a 
 pneimionia would have really made the case any stronger. 
 And, after all, the man was dead. A healthy, sober man, who 
 had never before spent a day in bed, died sixteen days after 
 the accident while under treatment for flatulence and constipa- 
 tion. He died of " delayed shock," as it is called, truly and 
 Tmquestionably, as did the persons whose cases I have already 
 narrated, and as every day do people die who have broken a 
 femur, or have been burnt, or suffer from post-operative ileus. 
 
SHOCK 43 
 
 It is not necessary to labour the point that in this, as in 
 other cases, the trauma was unexpected. But it links these 
 fatal cases with the non-fatal ones, in which, equally, there 
 is no symptom that may not be referred to functional 
 derangement — namely, those of traumatic neurasthenia, 
 wherein also it is clear that the protective mechanism of 
 the body is taken " off-side." There is no time for pre- 
 paratory adjustment of the blood-distribution in the body 
 to the purpose. And it is then easy to understand how, given 
 a high shock value, under such circumstances the protective 
 adaptation may be out of all proportion to the occasion, as 
 when the telephone operator is excited by a rimiour of fire. 
 
 What the exact significance of the latent interval is, it is 
 difficult to say, but it must be observed how generally there 
 is some flatulence, which in slighter cases may pass as due to 
 dyspepsia, and in the more grave may lead to such distension 
 that the surgeon's aid is invoked. 
 
 Now this flatulence is not dyspeptic. It has, it is true, an 
 intimate relation to the flatulence of what is called " neurotic 
 dyspepsia," but, as I have tried to show elsewhere, this 
 flatulence too is an affair of actual gas secretion from the 
 stomach and bowels, and brings the shock cases we have been 
 discussing into line with those of acapnia, to which so much 
 attention has been directed by Professor Henderson of Yale, 
 and Dr. Crile. 
 
 Now, in all these curious cases in which gas secretion occurs 
 three systems are involved — the vasomotor, the autonomic 
 nervous, and the adrenal. 
 
 The direct connection between the adrenal system and the 
 production of gas in shock and in acapnia has, I think, had 
 light thrown on it recently by Falta and by Fuchs, who have 
 shown that the adrenal system not only provides, as we 
 know, a substance that influences the tone of the bloodvessels, 
 heart, stomach, bowels, and other organs, but a substance or 
 substances that seemingly control the internal respiration — 
 the exchange of gases between the tissues and the blood. If, 
 then. Cannon is right in holding the adrenal or chromaffine 
 system responsible for the adjustment of the body in cases of 
 shock, we can understand how it is that the sjmiptom of 
 flatulence, though present in varying degree, is a thread link- 
 ing many of these conditions together. 
 
 Whether this gas secretion is indicative of exhaustion of 
 
44 SHOCK 
 
 the adrenal system, or whether it marks the excessive activity 
 that heralds exhaustion, or whether it is sometimes or always 
 an expression of perversion, rather than of excess or deficiency, 
 it is hard to say. On the answer to these questions depends 
 probably determination of the treatment that we should 
 prescribe. 
 
 It is not my desire to pursue here the purely medical aspects 
 of these questions ; I have done that elsewhere. My object 
 is to show that there is a definite connection between sudden 
 death from inhibition ; surgical shock as we see it every day 
 in hospital ; post-operative ileus ; the apathetic death of a 
 warrior's lady " without apparent reason " ; cases of delayed 
 shock ; deaths from pneumonia after some injuries ; and, 
 lastly, traimiatic neurasthenia. 
 
 The cHnical manifestations of shock are, and must be, as 
 various as the diverse circumstances that evoke it, and the 
 natures of those in whom it is evoked. It seems certainly 
 as if the visceral incidence of shock is sometimes in proportion 
 to the psychical repression, and that an adequate fit of hys- 
 terics may be an excellent safeguard against traumatic neuras- 
 thenia. But it is a very practical lesson that, whether lawyers 
 or physicians, we should hesitate to disregard " functional 
 symptoms " merely because our dull eyes can find no organic 
 lesion, which, if we did, would probably be quite irrelevant 
 except as evidence that accident had occurred. 
 
 It is not an exaggeration, though it may seem a paradox, 
 to say that people do not die of organic disease so often as of 
 disturbances of function ; although, after all, there can hardly 
 be functional disturbances without alteration in cellular 
 states. 
 
 Something may even be said for the malingerer. " I do 
 not recollect," says Murri, " ever having come to the con- 
 clusion, in a case of so-called ' traumatic neurosis,' that the 
 whole affair was a deception." 
 
 Be this as it may, if we are to recognize, as I think we must 
 increasingly, that even the simple or apparently simple func- 
 tional perturbations of which people complain or from which 
 we see them suffer, after physical or psychical trauma, are 
 really consequences not within their control, though pos- 
 sibly dependent on their personal equation, I can foresee a 
 revolution in the attitude of insurance companies towards 
 accident. I do not think that we doctors have any right, 
 
SHOCK 45 
 
 except as citizens, to express an opinion as to who should or 
 who should not be compensated by the State or the em- 
 ployer under certain conditions. We must stick to our last, 
 and elucidate as honestly as we may the chain of circumstances 
 in each case. 
 
 Lawyers will doubtless find a congenial field in devising 
 formulae which will secure that those receive compensation 
 who public opinion determines should be compensated, and 
 that others, who enter into private contracts with insurance 
 companies, be justly dealt with. 
 
 Anyway, the responsibihty for the enunciation of the prin- 
 ciples of compensation does not, I take it, rest with either 
 lawyers or physicians as such, though it is our duty to point 
 out where existing statutes or usual forms of policy operate 
 inequitably, or not as intended by those who have devised 
 them. 
 
 When all is said and done, there is still the element of 
 suggestion, and I do not see why we should hold anyone 
 responsible for his personal " suggestibility." There is no 
 doubt, too, that the effects of trauma, physical and psychical, 
 are tending towards exacerbation as a result of the ever- 
 present suggestion of compensation which operates, through 
 the trauma, on the autonomic system. And it seems to me 
 that the " suggestibility " of any person is not easily to be 
 distinguished from what Mr. Tyrrell Gray calls his " shock 
 value." 
 
 The practical notion that I put forward is that, just as we 
 attempt to assay the life- value of any candidate for life in- 
 surance, so must we address ourselves to estimating the 
 " shock value " or suggestibility of persons who are to be 
 insured against accident. 
 
LIST OF AUTHORS WHOSE WORKS HAVE BEEN 
 CONSULTED AND REFERRED TO. 
 
 Allbutt, Sir T. C. A. : System of Medicine, vol. iii., p. 386 et seq. 
 
 Armour : Clinical Journal, March 15, 1905. 
 
 Barry : Universal Medical Record, March, 1912, p. 277. 
 
 Begg : Veterinary Joiornal, August, 1912. 
 
 BiNNiE : Surgery, GynsecologA^, and Obstetrics, May, 1912. 
 
 Brouardel and Benham : Death and Sudden Death. 
 
 Brunton, Sir Lauder : System of Medicine, vol. iii. Proceedings of 
 
 the Royal Society of Medicine, April, 1912. 
 Cannon : Boston Medical and Surgical Journal, August 8, 1912. 
 Cannon, Shohland, and Wright : American Journal of Physiology, 
 
 April and December, 1911. 
 Cotton: Boston Medical and Surgical Journal, September 26, 1912. 
 Crookshank : Essays and Clinical Studies, pp. 288 et seq. 
 Dejerine : Universal Medical Record, February, 1912. 
 Dent, T. Clinton : Clinical Journal, October 7, 1908. 
 Enriques and Gaston Durand : La Presse Medical, October 9, 19 12. 
 Eusterman : Mayo Clinics, 1910. 
 
 Evans, H. Muir : British Medical Journal, vol. i., 1897, 
 Falta and Priestley : Berlin, kltn. Wochenschrift., November 20, 
 
 1911. 
 Fenwick, Soltau : System of Medicine, vol. iii. 
 Franke : Universal Medical Record, October, 1912, p. 328. 
 FucHS and Roth : Zeits. fiir Path., vol. x., p. 187, 1912. 
 Go\vERS, Sir W. : Lancet, 1907, vol. i., p. 1551. 
 Gray, Tyrrell, and Leonard Parsons : British Medical Journal, 
 
 vol. i., 1912. 
 Grayson : Journal of the American Medical Association, May 25, 1912. 
 Held : Medical Record, August 24, 1912. 
 Hemmeter : Interstate Medical Journal, March, 1912. 
 Henderson, Yandall : American Journal of Physiology, vols, xxiv., 
 
 XXV., xxvi., and xxvii. Surgery, Gynaecology, and Obstetrics, 
 
 August, 1911. (See also Worsley, ibid., April, 1912.) 
 Herschell : Interstate Medical Journal, March, 1912. 
 Hoppe-Seyler : Vide Wylie. 
 
 Hoskins : Cleveland Medical Journal, March, 1912. 
 Hutchison : Applied Physiology, p. 251. 
 Jordan, Furneaux : Surgical Enquiries. 
 Knocker : Accidents in their Medico-Legal Aspect. 
 Macdonald : Canadian Medical Association Journal, April, 1912. 
 Mackenzie : Medical Chronicle, 1892. Diseases of the Heart. 
 Mayo : Vide Starr. 
 
 Meunier : Universal Medical Record, April, 1912, p. 334. 
 MouLLiN, Mansell : Pathology of Shock. Ashurst's Encyclopaedia 
 
 (art.: Shock). 
 
 46 
 
LIST OF AUTHORS 47 
 
 Murphy and Vincent: Boston Medical and Surgical Journal, 1911, 
 
 p . 684. 
 MuRRi : Universal Medical Record, July and August, 1912. 
 Neuhof : American Journal of the Medical Sciences, May, 1912. 
 OsLER, Sir W. : Principles and Practice of Medicine. Universal 
 
 Medical Record, Januarj^ 1912, p. 31. 
 Page : Injuries of the Spine and Spinal Cord. Railway Injuries. 
 Rankin, Guthrie : British Medical Journal, vol. ii., 1911. 
 Sajous : The Internal Secretions, vol. i., p. 235. Monthly CyclopaBdia 
 
 and Medical Bulletin, December, 19 ii. 
 Sherrington : Encyclopaedia Britannica, vol. xxvi., p. 287. 
 Starr : Canadian Medical Association Journal, March, 1912. 
 Stone, Bernheim, and Whipple : Bulletin of the Johns Hopkins 
 
 Hospital, June, 191 2. 
 Strauss : Ibid., February and April, 19 12. 
 Taylor : Practice of Medicine. 
 
 Thompson, Campbell : Clinical Journal, May 22, 1905 ; June, 1912. 
 Trousseau : Clinical Lectures (New Sydenham Society), vol. iv. 
 Turner : Clinical Journal, July 24, 1907. 
 Verdon : Lancet, June 8, 1912. 
 
 Verworn : Bulletin of the Johns Hopkins Hospital, April, 1912. 
 Vincent : Internal Secretion and the Ductless Glands. 
 Watson, Wadsworth : Liverpool Medico-Chirurgical Journal, January, 
 
 1912. 
 WiLKs, Sir S. : Lectures on Diseases of the Nervous System. 
 Winternitz : Bulletin of the Johns Hopkins Hospital, April, 191 1. 
 Wyllie : Edinburgh Hospital Reports, 1895. 
 Yeo, Burney : Food in Health and Disease, p. 403. 
 
 Some account of the swimming-bladder of fishes may be 
 found in the " Encyclopaedia Britannica " (art. Fishes). 
 
 The case of Etherington may be read in any law library by 
 reference to K.B., I., 591, 1909. 
 
 ERRATA 
 
 Page 37, footnote, for " Grave's " nad "Graves's." 
 Page 46, Une 16, for " Medical " read " Medicale." 
 
 line 30, /o»' "Yandall" read "Yandell." 
 
 line 34, for " Wylie " read " Wyllie." 
 Page 47, line 6 from end, for " Watson, Wadsworth " read " Wads- 
 WORTH, Watson." 
 
LIST OF AUTHORS WHOSE WORKS HAVE BEEN 
 CONSULTED AND REFERRED TO. 
 
 Allbutt, Sir T. C. A. : System of Medicine, vol. ui., p. 386 et seq. 
 
 Armour : Clinical Journal, March 15, 1905. 
 
 Barry : Universal Medical Record, March, 1912, p. 277. 
 
 Begg : Veterinary Journal, August, 1912. 
 
 BiNXiE : Surgery, GjTisecology, and Obstetrics, May, 1912. 
 
 Brouardel and Beneam : Death and Sudden Death. 
 
 Brunton, Sir Lauder : System of Medicine, vol. iii. Proceedings of 
 
 the Royal Societ^^ of Medicine, April, 1912. 
 Caxxox : Boston .Medical and Surgical Journal, August 8, 1912. 
 Canxox, Shohlaxd, and Wright : American Journal of Physiology, 
 
 April and December, 1911. 
 Cotton: Boston Medical and Surgical Journal, September 26, 1912. 
 Crookshank : Essays and Clinical Studies, pp. 288 et seq. 
 Dejerine : Universal Medical Record, February, 1912. 
 Dent, T. Clinton : Clinical Journal, October 7, 1908. 
 Enriques and Gaston Durand : La Presse Medical, October 9, 19 12. 
 Eusterman : Mayo Clinics, 1910. 
 
 Evans, H. Muir :' British Medical Journal, vol. i., 1897. 
 Falta and Priestley : Berlin, klin. Wochenschrift., November 20, 
 
 1911. 
 v-c-K-ann-v: c^nT.TATr • SvstftTn nf Medicine, vol. iiL 
 
 
 c 
 
 / 
 
 
 / 
 
LIST OF AUTHORS 47 
 
 Murphy and Vincent: Boston Medical and Surgical Journal, 1911, 
 
 p . 684. 
 MuRRi : Universal Medical Record, July and August, 1912. 
 Neuhof : American Journal of the Medical Sciences, May, 1912. 
 OsLER, Sir W. : Principles and Practice of Medicine. Universal 
 
 Medical Record, Januarj^ 1912, p. 31. 
 Page : Injuries of the Spine and Spinal Cord. Railway Injuries. 
 Rankin, Guthrie : British Medical Journal, vol. ii., 1911. 
 Sajous : The Internal Secretions, vol. i., p. 235. Monthly Cyclopaedia 
 
 and Medical Bulletin, December, 191 1. 
 Sherrington : Encyclopaedia Britannica, vol. xxvi., p. 287. 
 Starr : Canadian Medical Association Journal, March, 1912. 
 Stone, Bernheim, and Whipple : Bulletin of the Johns Hopkins 
 
 Hospital, June, 1912. 
 Strauss : Ibid., February and April, 1912. 
 Taylor : Practice of Medicine. 
 
 Thompson, Campbell : Clinical Journal, May 22, 1905 ; June, 1912. 
 Trousseau : Clinical Lectures (New Sydenham Society), vol. iv. 
 Turner : Clinical Journal, July 24, 1907. 
 Verdon : Lancet, June 8, 1912. 
 
 Verworn : Bulletin of the Johns Hopkins Hospital, April, 1912. 
 Vincent : Internal Secretion and the Ductless Glands. 
 Watson, Wadsworth : Liverpool Medico-Chirurgical Journal, January, 
 
 1912. 
 WiLKS, Sir S. : Lectures on Diseases of the Nervous System. 
 WiNTERNiTZ : Bulletin of the Johns Hopkins Hospital, April, 1911. 
 Wyllie : Edinburgh Hospital Reports, 1895. 
 Yeo, Burney : Food in Health and Disease, p. 403. 
 
 Some account of the swimming-bladder of fishes may be 
 found in the " Encyclopsedia Britannica " (art. Fishes). 
 
 The case of Etherington may be read in any law library by 
 reference to K.B., I., 591, 1909. 
 
 H. K. LEWIS, 136, GOWER STREET, LONDON, W.C. 
 

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