' Some will be interested to know that the new occupant of the Chair of Pathology can write nearly half the letters of the alphabet after his name.
Others will prick up their ears on hearing that he is a Double Blue and Double Half-blue of Edinburgh University. Many will be all attention when told that he left his native land, Scotland, for New Zealand at the age of 11 months, and will be anxious to know if it was "for his country's good." But the thing that interests us all is the man himself. And in this connection there are some points in his history that are of interest. The first is that he was chosen as Canterbury College representative for the New Zealand Rhodes Scholarship, and the second is that he had four and a half years of active service, during which he gained a Military Cross at Ypres—where they were not handed out with the rations—
and two mentions in despatches. These facts, when taken in conjunction with the inspiring impression of ideals he gave to the M.S.S. annual meeting, tell us that Professor MacCallum is possessed of more than his fair share of that vague quality which the Americans inadequately call "pep," and which we, with greater erudition, but no more adequacy, call "personality." And this is, above all things, a requisite for a teacher in the Medical School, where personal influence and example count almost as much as learning.
We have heard some rumour of lectures being delivered in plus fours. In this point we wish to state, without any heating about the bush, that, like Dis- raeli, we "are on the side of the angels." We find that our own best work is done in a dinner jacket and shorts, and we claim that each has a right to choose that costume which best expresses his own individuality.
boiiLbcr pain in 112uptiireb ctoptc pregnancy anb a Fillic0 ConOition.
A writer to the Boston Medical and Surgical Journal gives an interesting resume on shoulder pain as an aid to the diagnosis of ruptured ectopic pregnancy.
He recalls that, though none of the books on gynecology mentions this symptom, Behan, in 1914, in an article on Extra-uterine Pregnancy, wrote : "In some cases the pain is referred to the shoulder. In these cases it is possible that the blood may extend as high as the diaphragm, and so irritate it ; the irritation, in turn, is transmitted through the phrenic to the supra-acromial nerve, and so causes pain to be referred to the shoulder."
"Cope, in 1922, wrote : 'Sudden hypogastric pain, associated with symptoms of collapse and accompanied by shoulder pain, in an adult woman should make one think of ectopic gestation. If the pain is felt over both clavicles or over the right clavicle, the diagnosis of ruptured ectopic pregnancy is almost certain.'
"Cedarberg observed that the pain occurred in paroxysms of extreme severity, and that it was aggravated by deep respiration. The majority of his patients referred the pain to the right side alone, but in at least one it was strictly limited to the left side, and in several both sides were affected, with occasional radiation down the arms. The right shoulder was painful in one case where
THE SPECULUM. 29 the left tube was ruptured, showing that the rupture cannot be localised from the shoulder pain."
The writer points out that "even when on the alert for phrenic shoulder pain, there may be some difficulty in differential diagnosis. The shock and col- lapse—the indications of sudden internal hwmorrhage which frequently follow rupture of an ectopic pregnancy—are not often seen in other abdominal condi- tions which cause irritation to the diaphragm. In perforation of a duodenal or pyloric ulcer, the pain is usually felt in the right acromion process ; less com- monly the patient will locate it above the right clavicle. Rupture of an infected gall-bladder may produce the pain, but as a general rule the pain will he ref erred to the right supraspinous fossa, or occasionally, to the acromio-deltoid region."
Cope, however, states that "if the question is put as a routine" to all patients complaining of pain in the shoulder who are suspected of being cases of- rup- tured ectopic gestation, "it will be found occasionally that pain is complained of in the supraspinous fossa and over the acromio-clavicular joint and deltoid."
A recent case at the Alfred is illuminating. A woman, aged 29 years, no history of miscarriage, had one child, a heavy boy of two years, whom she was in the habit of carrying. Menstruation had always been regular, the last period being on May 26. While in bed at midnight of June 17, she was seized with severe pain in the lower central abdomen. The attack was accompanied by weak- ness and marked pallor (observed by her husband). She left her bed to obtain relief, but after two or three minutes on her feet, fainted, and had to be lifted back into bed. On five subsequent occasions she left her bed with the same result, the last fainting attack being almost simultaneous with her exit from bed.
The pain spreading and growing more acute, brandy was administered, but was vomited 10 minutes later, with the remains of the evening meal.
At 6 a.m. the doctor arrived, and after examination advised immediate re- moval to hospital. At the movement occasioned by his examination she ex- perienced sudden stabbing pains in both shoulders, shooting up into the neck, and .radiating down the arms. The intensity of these pains quite eclipsed that in the abdomen, their severity causing her to scream. On cessation of the move- ments caused by examination, these pains gradually subsided.
At 10 a.m. the patient arrived at hospital. She was markedly pale, and in considerable distress. Temperature 99 deg., pulse 120, respiration 40, B.P. 98.
Moderate abdominal distension and general tenderness, the most sensitive point being in the right umbilical, about 2 inches above MacBurney's point. During examination she experienced a severe attack of neck-and-shoulder pain. Investi- gation of the shoulder pain showed it to be in the supraspinous fossa, and over the deltoid and acromioclavicular joint, being slightly more marked on the left side. Radiation occurred down the arms, and along the line of the phrenics into the neck. Vaginal examination revealed no bleeding, but there was extreme tenderness, especially to the left side of the cervix.
Diagnosed as ruptured etopic pregnancy, and operated on one hour later.
On being removed to the operating theatre she experienced a further attack of neck-and-shoulder pain, more acute than the last, with consequent screaming.
Laparotomy disclosed the peritoneal cavity full of blood, and the source of ' bleeding a cavity in the right ovary. The blood and ovary were removed, the latter being kept for microscopic section.
Two days after the operation (June 20), and one week before the next expected period, the patient menstruated. The amount on the first day was
somewhat excessive, but the period thereafter proceeded normally (four days), nothing of import being detected in the discharge.
-Recovery was rapid, the patient experiencing no further neck or shoulder pains, and only some slight abdominal discomfort for the first day. She was able to leave hospital on the thirteenth clay.
Microscopic examination of the removed ovary, some days later, showed the lesion to be a ruptured hxmorrhagic corpus luteal cyst.
—A.M.H.
C. 1P. 71:1)mo3.
i.
To Jimmie Bell, from near and far, They bring their tummies sore ; He prods them and he pushes them,
And then, to find out more,
Test meals, X-rays, and stomach tubes, And bio-chem galore,
Are all employed, tho' not enjoyed By patients, who deplore
How science, aiding Dr. Bell, Can make their days a merry hell.
II.
Tell a tale of Thomson, Buckets full of gore ; Four-and-twenty tonsils
Enucleated raw.
When their mouths are opened, The kids begin to bleed, A bluggy operation,
Requiring lots of speed.
III.
When bugs invade the throat of Maurice, His ma comes down to see
Our genial, rotund Dr. Norris, Who spots the K.L.B.
He tells what baby ought to eat, Checks the precocious spirochxte, While kids with D. and V.,
Or temps., or "pneu.," or rheumat I C K S, He tucks up into cots in Micks.
THE SPECULUM. 31 IV.
Let us tell without preamble Of patients seen by Dr. Gamble.
No cuts or bruises, pains or aches, Worry the people whom he takes.
At girls who hear "voices" he simply rejoices, And psychically studies their trouble ;
In realms of subconscious, inquiry he launches, And tracks personalities double.
Tho' mental cases make US ramble, They're bread and jam to Dr. Gamble.
--P.V.
1bar0 as a %tone.
He certainly did look rather like "something the cat brought in" when the tram had finished with him, but a hurried examination revealed nothing worse than a fractured right ulna, various small cuts and abrasions, a rather deeper cut over the left eye, which had missed the artery, and a strong suspicion of the usual C2H60. When I had seen him off in an ambulance en route for the M.H. I rejoined my cousin on the footpath, to find her looking rather white and shaken. To calm her I assured her that the victim was very lucky, one broken bone and a few cuts beinc, the sum total of his injuries. But again and again through the evening she kept harping back to the "poor man." She "wondered how he was getting on now." "Did I think they would have to operate on him?"
"Would he suffer terribly while his arm was being set?" and so on. To try to restore her to equanimity I assured her that the patient would recover from his half•stunned condition to find himself comfortably in bed with his worst troubles behind him; that if putting up the arm proved particularly painful he would be given an anaesthetic, and that there was no need in the world for her to worry herself to death about a very minor casualty who seemed to be, to a certain extent, responsible for his own condition. But nothing that I could say, no ex- planation or assurance from me, would convince her that she had not recently been the one witness of a ghastly accident, the victim of which was certain to progress by slow and agonising stages to a premature death. "I wonder i f he was married," she said suddenly, after a period of silence, "and how his poor wife will get on while he is in the hospital?" "Oh, for goodness sake, come and dance," I said impatiently ; "he'll be all right. If you like I'll look him up in the morning, and let you know how his agonies are progressing, and how many times he has moaned since admission, and what the eldest child's name is, and any other harrowing detail that you would like information on. But do leave it till the morning. The orchestra won't play for ever."
And then came the old accusation : "Oh, you meds., you are all the same ; you, and doctors and nurses. Hard as stones, the lot of you. About as much sympathy among you as there is in a tribe of cannibal savages. It nearly made me sick to watch the way you handled that poor man, the way you took hold of his poor arm and pulled and pushed it about, and poked and prodded at him as if
he were some sort of mechanical toy, and you wanted to see what tricks you could .get it to do for you! I heard him groan once, you hurt him so much ! And to think that you are going to be a member of the profession that boasts that its mis- sion is the alleviation of suffering ! And nurses are just as bad. I have heard one of them I know talking about her 'cases' just as if they were show-cases, full Of things designed for her interest and amusement. I think you must all be born with a bit of your brains lacking, the bit that deals with sympathy and pity."
As my cousin reached the end of her peroration the orchestra jazzed its .way through "God Save," and as she announced coldly that "she was perfectly capable of taking herself home," I came home by myself, wrapped in a garment of some- what chaotic thought.
And as I lay in bed that night the incidents of the evening came up for re- view, and the more I pondered on my cousin's words the more inclined was I to agree with her. Now I came to think of it, I had only the vaguest of ideas as to the personal appearance of my "patient" of the evening. I knew he had a cut on his forehead which had missed the artery, but I didn't know the colour of his eyes. I could have made a most exact sketch of his right forearm, and I knew that his breath smelt of whisky, but I hadn't even asked him if his wife—if any
—would be upset at receiving the news. "Damn it all," I thought, "I was fright- fully inhuman with the poor devil. I examined him as a boarding-house keeper examines the joint for Sunday, but with considerably less emotion. And now I come to think of it, I seem to examine all my cases rather like that. And I am filled with 'satiable curtiosity' until they come to operation, and I do at last see what really is the cause of their symptoms. A pain is just a 'symptom' to me.
I no longer look on it, as I used to at one time, as being one of the most extra- ordinary phenomena in a scheme of things created by a Being who, we are told.
is all-wise and all-merciful. Pain used to be for me a mystery, an anomaly, a cause for speculation Now it's just a symptom, and once I have found out
`what sort of a pain' it is it leaves my consciousness, and passes into that limbo of oblivion which we have named 'the sub-conscious mind,' causing no more mental disturbance en route than the passage of a fly across her deck alters the trim of an ocean liner. And yet I can remember the time when I started at the hospital, and suffered acutely at the sight of pain; the time when it was a real misery to me to dress a fractured tibia that was in my charge, because, try as I would, I could not avoid inflicting a certain amount of pain on my patient.. But now, I'd go and tie his leg in knots round his neck with never a tremor, though he shouted the roof off, if I thought it would do him any good."
And it was at that particular spot in my train of thought that a ray of light dawned upon my somewhat gloomy cogitations, "If I thought it would do him any good " That is the point. That one phrase explained the whole thing. In examining my tram car friend I had deliberately manipulated his arm until I caused him pain. Was it because I got any enjoyment out of hearing him groan?
No; but because one of the few things I had managed to learn was "The Cardinal Signs of Fracture," where "pain" holds a chief place. Having by this and other means established the fact that his arm was fractured, I was in a posi- tion to "do him some good" in the way of putting and keeping the arm in the safest and most comfortable position during his transit to hospital. In short, I have learned that pain is not the inscrutable mystery it seems to a layman, but is Nature's warning signal that something is amiss With the complex mechanism of her most wonderful machine. And it is by no mr ans the least of man's triumphs in the art of healing, that he has learned to use this warning signal for
THE SPECULUM. 33 his own ends. By careful observation of the site, nature, and so forth of this outstanding symptom of a great number of morbid conditions we are enabled to state with fair accuracy what is the cause, and from this to cure is often a mercifully short and easy step.
So, by slow degrees, I revised my changed attitude of the last few months, from the day when the snoring-of a patient under a deep anaesthesia would almost drive me from the operating theatre, to the present, when I can assist in the putting up of a fracture, say, without a qualm at the occasional twinge of pain inflicted on the patient, secure in the knowledge that the best is being done to ensure his present comfort and his future well-being. And I realised that my mind was not being dulled by callous custom, but sharpened by knowledge. I saw that, in the presence of disease and suffering, it is worse than useless to indulge in "weeping and wailing and gnashing of teeth," but rather carefully to suppress those natural feelings of compassion that often tend to be uppermost in our minds, in order that the skill and learning of long training may not be hampered by sentimental considerations. Our mission is to alleviate suffering, not to weep over the sufferer.
I have often thought that it would be an education to those—and they are not a few—who say that the members of the medical profession, and our nursing sisters, are unsympathetic, to "do a round" with an honorary physician or surgeon some morning through the wards of one of our hospitals. Then - they would learn that true sympathy is not an uninhibited outpouring of incoherent sentimentalities, but a visualising of the true meaning of suffering in a fellow- creature, coupled with the desire and the ability to abolish or, -at least, to lessen, that suffering by every means known to modern medical science.
Having worked out this apologia pro Vita mea„ I wrote a condensed version of it to my cousin next morning. My letter crossed one from her, apologising for having made herself so unpleasant the night before, "but I had a beast of a headache, and felt rotten. I hope you won't take any notice of the nonsense I talked, and will come over to tennis on Sunday as usual."
"Vraiment, elles-sont des chosen droles, ces femmes-ci."
—LUKE.
Obituarp.
It is with deep regret that we have to record the death, on April 17, of Victor S. H. Osment, in the 38th year of his life, and in the fifth year of his medical course.
During his tour of duty at the Children's Hospital he contracted tonsilitis, which proceeded to quinsy. Shortly afterwards it was found that thyroiditis was present, and an abscess formed, which, on being opened, was found to be caused by streptococcal infection. Death from septicaemia took place a few days later. So passed from our midst one who will live long in the memories of those who were privileged to know and work with him.
Victor Osment had a very interesting life, interesting in two senses of the word. It was interesting, because all that he did, or saw, or heard, interested him. The charge could never be laid at his door that he was the typical med., only able to join in a conversation that had as its subject his particular branch of study. He could talk well on many aspects of life, and always had something
C