INFECTIVE OSTEOMYELITIS iN CHILDHOOD. 53

diet sheet. He likes to be told that he may eat crab,but on no account lobster. At least, the moresuggestible dyspeptic likes it. And there are somephysicians who enjoy telling him that he can eatwhiting but not plaice. I believe this procedure to befundamentally mistakeni. Dyspepsia is not diabetes,nor yet arterio-sclerosis. It is right and properthat in such diseases we should authoritatively setdown what is allowed and what is forbidden. Ourinformation comes from the laboratory, and thepatient has little or no means of helping us. Butwhen it comes to dyspepsia we have not onlylaboratory findings, but the patient's experience toguide us, and we should welcome that experienceas an indication of his idiosyncracies. Instead ofthat, sonme of us are tempted to show our profoundknowledge of dietetics by forbidding an article thatthe patient hadl always imagined agreed with himparticularlv well. If he be sufficiently suggestiblehe will go honie and tell his wife how clever we are,and never touch the article in question for months,and then in a moment of self-assertion indulge init and suffer for the first time. I believe that sounddietetics demand that we should carefully studythe patient's report of what agrees and what doesnot agree with him, and stimulate him to carefulobservation in a detached spirit. We frequentlytrade on the fear of the dyspeptic, and make himmore apprehensive than ever in regard to diet.

THE FEAR-PROCESS.I have said that fear promotes dyspepsia. Not

only does it do so in the way I have shown, butalso by the ordinary mechanism of the sympatheticnervous systeiii. If we tell a victim of mild hyper-chlorhydria that unless his symptoms soon clear upwe shall have to operate on a presumptive duodenalulcer, we establish a fear-process. That fear-process morks just like any other fear-process, beit the fear of bankruptcy or the fear of shipwreck.It stimulates the adrenals, and their secretion inturn stimulates the thyroid; all unstriped musclebecomes hypertonic ; all the arteries are constricted.As a result we have a more or less violent interfer-ence with two factors of digestion: (a) peristalsis,and (b) the vascularity of the mucosa. The propercure for this condition is not atropine, but analysis.The fear of dyspepsia may have increased thedyspepsia. That is generally the physician's fault,and he had better retrace his steps. Or fear mayhave produced dyspepsia. In that case thephysician had better find out what the fear is.Only those who have experience of meental analysisrealise the pathogenic importance of the fears ofthe man who begins by saying that he has nofear. When we satisfy ourselves so easily that thepsychological factor may be ignored, we are likelyto lan(d ourselves in the most usual and most bafflingof all therapeutic quagmires-that of treating withphysical remedies a condition that is based onemotional causes.

[The opening remnarks on the .Mfedical Aspect of thequestion vill be published in our ne.xt nuinber.-ED.]

INFECTIVE OSTEOMYELITISIN CHILDHOOD.

iIY

H. A. T. FAIRBANK, I).S.O., -M.S. LOND.,F.R.C.S. ENG.,

SENIOR SURGEON, HOSPITAL FORt SICK CHILDRIEN; SE'NiORORTHOP.ED)IC SURGEO'N, KING'S COLLEII HOS:PITAL.

By this title I mean an osteomyelitis, acute?subacute, or chronic, due to one ef the pyogenicorganisms, excluding those due to tubercle andsyphilis. From the pathological poinit cf view-osteomyelitis may reslult in rar faction, in sclerosisor necrosis. The particular result that we seedepends on the viruilence of the affecting organism.An acute infection is more likelv to lead to somerarefaction, and particularly to necrosis; a chronicone to rarefaction or sclerosis. These cases ofinfection cf bone used to be classified into myelitis,osteitis, and periostitis, but, speaking generally,every inflammation of bone which has lasted formore than a day or two involves all these structures,periosteum, bone and marrow, wherever it begins.The trouble usuially starts in the scft bone at theend of the diaphysis as an osteitis, affecting thecancellous tissue at the end of the bone, and vervsoon getting into the medulla and causing a myelitis.Periostitis does occur as the essential part of aininflammatory lesion, but only exceptionallv. Theperiosteum is only affected secondarily in theordinary cases which we see and which we arcconsidering to-day-i.e., the ordinary acute inflam-mation of bone in children. We occasionally seea lesion where the infection is very (lefit itely limite(dto one side of the bone, and, therefore, looks ratheras if it began as a periostitis, but the possibilityof acute periostitis occurring by infectioin throughthe blood stream can be disregarded. The causativeorganisms are various, the commonest undoubtedlybeing the Staphylococcus aureus. Fraser, ofEdinburgh, some time ago noted the infectiveorganisms in 200 cases: in 61 per cent. he founclStaphylococcus aureus, and 29 per cent. pneumo-coccus, so that these two grouips representedl90 per cent. of the cases. Six per cent. gre-streptococci, and '3 per cent. the StaphylococcusaTbus. Occasionallv utnexpecte(d organisms occuras the cautse of this condition. F'or instance,Dr. Nabarro tells me there have recently been twocases in this hospital where Bacillus paratyphosus Bhad caused an osteomyelitis without any ante-cedent or present infection of the bowel; the bonelesion seems to have been the only lesion wherethe organism +was founcd. One cf these cases provedfatal. Typhoid osteomyelitis has, of course. beenrecognised for many years, though it is not seenmuch nowadays since typhoid fever has becomeso much less common.

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54 INFECTIVE OSTEOMYELITIS IN CHILDHOOD.

MODE OF INFECTION.The usual point of entry is through the throat

and mouth--septic and carious teeth and infectedtonsils and adenoids being responsible. Boils andseptic sores of the skin also sometimes form a modeof entry for the organism. The infection is alwaysblood borne; it is carried round in the circulationuntil it happens to lodge in a particular bone andcauses an acute. inflammation. Occasionally wefind that a joint becomes infected through theblood stream, and that the bone is infectedsecondarily, but this is usually merely an erosionof the ends of the bones following the acute arthritis,and is quite distinct from the type we are discussing.We also exclude those cases due to compoundfractures, so manv of which were seen during thewar and whicb rarely occur in children. In theordinary type, with no wound at all, the infectionis always blood borne. In early infancy theumbilicus is a possible mode of entry of the infection,but personally, I am of the opinion that it is morecommon to get a streptococcal arthritis from thissource than an ordinary osteomyelitis. In someof these cases the arthritis is primary, and in someit is secondary to infection of an epiphysis. Nowa-days we consider that a blood infection of a mildtype is a common occurrence, but, fortunately, theorganisms do not get much chance of multiplying-they get killed out as soon as they get into the bloodstream, while some are excreted in the urine, andso on. Repeated and mild septicsemia in childrenis common. Onlv in a certain proportion of thecases do the organisms settle in some portion of thebody-e.g., the end of a bone-and set up an acuteinflammatory lesion.

PREDISPOSING CAUSES.Anything which lowers the resistance may be a

predisposing cause of osteomyelitis. The exanthe-matous fevers, for example, accompanied as theyoften are by sore throat, and particularly scarletfever, obviously favour the entrance of pyogenicorganisms into the blood stream. With the excep-tion of typhoid fever the bone infections complicat-ing the ordinary acute fevers of childhood aresimilar to those which occur apart from such.I do not believe there is any particular form ofosteomyelitis associated with measles, scarletfever, &c., but that such infections are due to thelowered resistance of the patient, aided by an easymode of entry for the common pyogenic organisms.l may mention, at the same time, that in my opinionthis holds good for the forms of arthritis whichsometimes complicate these fevers. With theexception, perhaps. of scarlet fever, in which a typeof rheumatic arthritis occurs, I think these boneand joint infections are the same as those arisingfrom other sources, and without any antecedentexanthematous fever. In cases of pneumococcalo3teomyelitis a certain number, though not all,have a history of antecedent pneumonia orbronchitis. As to the particular age at which acuteinfections of bone oceur, some people say that

6 is the commonest age; at any rate, it is under12 years. The condition occurs much less commonlyin adolescents.

I might here say that the older the child the morelikely is the infection to be a severe one whichthe typical text-book description will suit. Theyounger the child the more likely is the case torun a subacute course. Older children are muchmore likely to get a virulent infection with severetoxwamia, high temperature, and, perhaps, rigors,&c. I do not see any reason for the infectionattacking children of 6 years or so in particular,except possibly that at this age they are more likelyto suffer from throat troubles of various sorts,whereas a great many of the older children have hadtheir tonsils removed. Growth is certainly not morebrisk, I consider, at this age than at other timesduring the growing period. Surely at pubertygrowth is much more brisk; a boy of 16 may growseveral inches in a few months, and a girl may dothe same at a rather younger age. Anotherfeature which is drawn into the etiology is trauma;this is rather a difficult question to decide upon.A history of trauma is very often absent. Blowsare said to produce damage which lowers the localresistance and favours the incidence of osteo-myelitis at the injured spot. If this were so weshould surely expect the periosteum or sub.periosteal bone to be first infected, which is certainlynot the case. Juxta-epiphyseal strain must bethe lesion if trauma is playing a part, and yet incases where clinically we know that an epiphysisis loosened, we certainly do not get an osteomyelitis.At the same time, I am not prepared to excludetrauma altogether. As regards sex, boys are muchmore commonly affected than girls, the differenceaccording to some authorities being as much as6 to 1. We must admit that trauma is morecommon in boys. As regards the bones affected,the order of frequency is as follows: Tibia, femur,humerus, ulna, radius. The scapula, spine, fibula,and ilium are occasionally affected, but very rarely.The tibia is certainly by far the most common site.

PATHOLOGY.What are the pathological changes which take

place in acute osteomyelitis ? As we have seen,the micro-organisms may be entering the bloodstream constantly from the source of infection,whatever this may be. Some of these organismsbecome lodged in a particular bone. The diseasealways begins in the metaphysis--i.e., at the endof a long bone near the epiphyseal line, and notnecessarily the main epiphyseal line; we find itbeginning, for instance, near the great trochanter,and even near the lesser trochanter, though in thefemur it is much more common at the lower end.

This curious fact of the commencement of theinfection being localised to the part of the bonementioned above has not been explained. Theterminal vessel arrangement has been suggestedas an explanation, for if one of these little vesselsbecomes blocked by organisms, a tiny portion of

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INFECTIVE OSTEOMYELITIS IN CHILDHOOD. 55

the growing bone is entirely deprived of its bloodsupply. This seems to me a more probable explana-tion than the suggestion that it is due to the greatvascularity of the part, to which some writersattribute it. There is, of course, a close networkof vessels in these actively growing ends of thebones, but I do not quite see why this should favourthe micro-organisms. In my opinion the greatervascularity of a part would favour the tissues andnot the organisms. I think some further explana-tion is necessary. The fact that each portion ofsoft tissue in the end of a bone is surrounded by asolid shell, and, therefore, cannot swell, must be avery important factor in deciding that the germshall win the fight.

Having begun in the cancellous bone the inflam-mation rapidly spreads to the periosteum on theone hand and the medulla on the other. Whatusually happens is this: there is an exudation offluid under the periosteum which is clear to startwith, and this lifts up the periosteum from thebone; in the ordinary staphylococcal infection thisfluid very soon becomes pus, so we have pusspreading up under the periosteum and pus spread-ing up the medulla, and pus spreading in the boneitself. The result is necrosis of a portion of the bone.On the outer side, where the periosteum is liftedup, the bone beneath is entirely deprived of animportant portion of its blood-supply. In the boneitself, where the swollen tissues are surrounded byunyielding walls, the pressure becomes great atonce, and the circulation very soon ceases, whilein addition the organisms themselves are producingvirulent toxins; all these things combine to leadto the death of a varying portion of the bone. Thisnecrosis will extend until the tension in the tissues isrelieved; in other words, until either the pus finds itway to the surface or the case is operated upon.

It is, therefore, obvious that the earlier a case isoperated upon the better for the patient from everypoint of view. Supposing it is not operated upon,the pus will find its way through the periosteumand an abscess will form in the muscles. Thisrelieves the tension to some extent, but onlyimperfectly. Nowadays, medical men are aliveto the possible diagnosis at once, and realise theneed for immediate intervention, though at onetime it was common enough to have cases comingto hospital which had been watched for so longthat the whole shaft of the tibia, for instance, hadbecome infected and necrosed. Separation of theepiphysis in such cases used to be common, but thisis not so now; it is seen nowadays most often at theupper end of the femur. Occasionally one seesboth epiphyses separated, with the shaft of theaffected bone entirely loose and necrosed.Occasionally the infection is of a less virulent type,and instead of acute necrosis occurring, the conditionis more or less chronic from the first, and a collectionof pus forms in the bone, while new bone is laiddown beneath the periosteum; this is one form ofBrodie's abscess. Radiograms show the abscesscavity as a more or less translucent area with

condensation and enlargement of the bone around.This condition can also occur as a late result of theacute type of osteomyelitis, when it is notuncommon to find a residual abscess at one endof the shaft months, or even years, after the acuteinfection has been efficiently dealt with at the other.

This reminds us that one particular infectiveorganism can, under varying conditions, beresponsible for inflammation of varying degreesof severity. The same organism can, in the samepatient, produce a chronic or subacute inflammationeither before or following a very acute condition.I have seen a dry arthritis of the hip-joint with asuppurative arthritis of the knee in the same leg;a non-suppurative arthritis of the hip with an acuteosteomyelitis of the opposite femur. A boy(radiograms were shown) came in with a very acuteosteomyelitis of the left tibia, from which he nearlydied. This began two years ago ; only after severaloperations were we able to get the leg to heal.Recently he came to hospital with a chronic osteo-myelitis of the ulna. I have not the least doubtthat both lesions were caused by the same organism.Now, what happens when the bone is opened up

and drained? Two processes invariably occur:first, there is a laying down of new bone to takethe place of that which is dead; and, secondly,a separation of the dead bone from the living. Totake the first one. Under the periosteum, whichhas been stripped up, but which usually retainsits vitality, a thick layer of new bone is laid down,the so-called involucrum, in which cloacae occur,through which the pus is discharged. This involu-crum is separated from the old bone where this isnecrotic, but is fused to the adjacent bone, whichhas just managed to retain its vitality. Theseparation of the sequestrum takes place as a resultof the growth of round cells and osteoclasts whicheat through the bone until they have separatedentirely the dead from the living.

TheoreticaIly, this separation should occur atthe expense of the living bone, just like an area ofmoist gangrene is freed at the expense of the livingtissue. At the same time there is probably a certainpower of destruction of dead bone, because thereis reason to believe that small sequestra can beeaten up entirely, and bigger ones can be brokenup. After the sequestrum has been removed, thecavity left gradually gets filled up with granulationtissue, scar tissue, and eventually bone. Thethickened bone gradually approximates to itsnormal size, though it rarely becomes quite normal.Unfortunately this is not always the case, even inchildren, and " bone cavities " remain, as can beseen in this radiogram, which shows a hole left bythe removal of a piece of dead bone. This cavitycannot by any possibility heal, because its solidwalls cannot shrink. If the cavity is widely openon one aspect the tissues may be drawn into it sothat the cavity is obliterated, but if the edges ofthe cavity are at all abrupt, or there is only a smallopening in the bony wall, this cannot occur. Itmay, however, heal up for a week, a month, or for

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INFECTIVE OSTEOMYELITIS IN CHILDHOOD.

many months, and then one day the latent abscesscavity flares up and the wound breaks down again.Several such cavities may be present in the shaftof a long bone, one or other flaring up at varyingintervals for many years. In many such a cure isnever obtained except by amputation. A mildinfection-e.g., by a pneumococcus or Staphylo-coccus albus--may give rise to a " serous osteo-myelitis "-i.e., the stage of serous effusion beneaththe periosteum is never passed, the trouble sub-siding without the formation of pus. Somesurgeons prefer to wait and see what will happenin cases of a mild type before operating, particularlywhere there is a history of pneumonia.As regards joint infection secondary to osteo-

myelitis, this should not be common, except incertain situations. The knee-joint is not usuallyaffected from the femur, though it can be. It iscommon to get a non-purulent effusion into theknee-joint, but this subsides when the osteomyelitishas been dealt with. Osteomyelitis of the upperend of the femur, on the other hand, is much morelikely to lead to suppurative arthritis, for obviousanatomical reasons. The hip, elbow, and knee arethe most likely joints to become infected secondarily.With regard to acute arthritis of infants, this

often begins as an acute epiphysitis. This is a veryfatal type of acute arthritis, and in some of thesethe infection begins in an epiphysis, and the result-ing abscess bursts into the joint through a smallhole in the cartilage. These holes have often beenseen at operation. The order of frequency of thejoints affected is as follows: hip, knee, shoulder,ankle, elbow, and wrist. Patients in this groupmay be as young as two months; in these earlycases the umbilicus is a probable source of infection.

SYMPTOMS.There is a stage of preliminary malaise, and then

sudden acute pain at the end of one of the longbones; this is very severe and is sudden. Thepatient shows signs of toxeemia-scanty urine,very high temperature, sometimes rigors in olderchildren, glandular enlargement, and leucocytosis.There is usually tenderness of the affected bonebefore there is any obvious swelling. The patientresents any approach to the limb or any movementof it. It is excessively tender, and in the youngerchildren the case seems almost like scurvy at thisstage. After a day or two there will be a littleswelling and redness, most marked on one aspectof the limb and situated towards the end of a longbone rather than at the adjacent joint. All theearlier symptoms are by this time increased. ThereI: ay, however, be a little easing off of the symptoms

the temperature being rather lower and the painless intense-which may be misleading. This isexplained by the fact that the pus has reached thesurface of the bone and is spreading under theperiosteum, and the tension is thus relieved a little.Later an abscess forms in the soft tissues, andfluctuation may be felt. Operation should beperformed, how-ever, long before this is possible.

DIFFERENTIAL DIAGNOSIS.What conditions have we to consider in the

diagnosis of this affection? With acute cellulitisof the tissues over the bone it is very difficult tolay down definite rules; if the swelling is towardsthe end of the bone, near to, but not of, a joint, itis suggestive of a bone lesion, while the generalsymptoms would in the latter case be much moresevere than if the superficial tissues only wereinvolved. Acute arthritis is not, as a rule, difficultto differentiate, except in the case of the hip-jointIt is sometimes extremely difficult to be sure, withan obvious lesion at the upper end of the femur,whether the hip-joint in addition is involved ornot. The same difficulty may arise in the courseof an operation when the trouble has begun in theupper end of the femur near one of the trochanters.In less acute cases osteomyelitis has to be diagnosedfrom fracture, but the greatest difficulty of all ismet with in the younger cases, where scurvy is a

possibility. In the latter condition an examinationof the urine for red blood-cells, and an inspectionof the gums may be of great help; a blood countshould be done. With regard to new growths,radiograms furnish the most useful evidence. Inchronic cases it is sometimes necessary to excludetubercle, but in this condition there is rarely anyperiosteal thickening, while there is a tendency togeneral rarefaction of the bones of the affected limb,such as is never seen in osteomyelitis. In osteo-myelitis the periosteal thickening of the bone isthe most important sign. In tubercular dactylitis,however, in contra-distinction to other bones,periosteal thickening is present.

PROGNOSIS AND TREATMENT.The prognosis in acute cases is always grave,

especially when the larger bones are involved, whenthe lesion is near the trunk, and when the case isvery acute, with marked signs of tox-emia. Lar-daceous disease sometimes occurs in these cases,and I have seen a child die from this disease in twomonths from the onset of the osteomyelitis.Adults have been known to die from lardaceousdisease within one month of the onset of acuteosteomyelitis following a gun-shot wound.Treatment.-In my opinion these cases should

be operated upon as soon as a diagnosis has beenmade, and in doubtful cases to establish thediagnosis. The only exception to this rule is inla chronic case (not subacute), where there is novery definite abscess and general symptoms areentirely absent. In these cases operation neednot be rushed at. In the ordinary acute or sub-acute case operation should be performed withoutany delay, the medulla being invariably openedwhere there is any elevation of the periosteum, an(lto the full extent of such elevation. In addition,if pus is found in the bone, the radical operationsuggested some years ago by Mr. Waugh should bedone, all infected bone being removed, even totwo-thirds of the circumference of the shaft.Cases treated in this way can heal up in the course

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ANTENATAL CARE. 57

of a few weeks with no sequestrum whatsoever.At the very least a good opening must be made inthe medulla. There is no sense in using a sharpspoon in the medulla-it does no good. What isnecessary is a free opening for the evacuation ofthe pus. Bier's treatment is useless in this, asin all other conditions. Vaccines seldom haveany effect. Antistreptococcic serum is of usein streptococcal cases. Plenty of fluid inust begiven-by mouth, per rectum, or subcutaneously;this is absolutely essential.

Blood transfusions are occasionally necessary indesperate cases. One more point with regard to theoperation. I do not consider that early total removalof the whole of a diaphysis is a sound procedure.It may be wise in chronic cases where there is agood deal of new bone formation, but not as aprimary operation in an acute case, unless the shaftis totally loose, but such a condition should neverbe allowed to occur. In removing sequestra in thechronic stages of the disease it is best to wait untilthese are loose, and then to leave a cavity of ashape that favours healing-i.e., one into whichthe soft tissues can fall with ease.

ANTENATAL CAREAS IT AFFECTS THE CHILD IN UTERO.*

BY

THOMAS WATTS EDEN, AM.D. EDIN.,F.R.C.P. LOND., F.R.C.S. EDIN.,

CONSULTING OBSTETRIC PHYSICIAN, CHARING CROSSHOSPITAL, LONDON.

(Contcluded from p. 39.)

THE F(ETAL PERIOD.Effect of -Maternal Diet.-A question related

to that which we have just considered, butin reality distinct from it, is whether specificdeficiencies in the mother's diet can influencethe development of the faetus. It is obviousthat, this may be so, although general in-sufficiencv of food may be without effect. Inits clinical aspect this question has hardly beenexplored at all, so far as I am able to find, but thereis a certain amount of experimental work whichI think deserves notice. In 1921 Reynolds andiMacomber published a series of observations onthe manner in which the fertility of rats couldbe influenced by feeding them on specificallydeficient diets. In his experiments he took acertain strain of albino rats which had been inbredfor 34 generations, and whose fertility-rate waswell determined. The rate was somewhat lowerthain that of rats of a heterogenetic strain.

For the purpose of his experiments the ratswere fed upon four different kinds of deficiency(liet; the deficient elements were not absent fromthe diet, but were present in quantity somewhat

less than the standard quantities of the stockdiet with which they are compared. The fourvarieties were:1. Low in fat-soluble vitamiin. 4. Double deficiency-i.e., low%%-2. Low in protein. in protein ai(l. fat-solublevitamiins, high in carbo-3. Low in calcium. hydrates.

The test consisted of determining the numberof matings which proved fertile, and resulted inlitters, under each form of diet, and the resultswere as follows-

Per cent. Per cenit.On stock diet 65 Oni (liet No. 3 31Oii diet No. 2 .. 55 On (liet No. 4 14

In addition to diminishing the niumber of fertilematings it was found that by continuing thedeficiency diet through several generations com-plete infertility could be produced. These infertilerats were apparently well-developed aninmals, withthe exception of those bred under a double-deficiency diet, which were feeble and undersized.The authors made a further very interesting

observation viz., that abortion with. a macerate(1fcotus occurred in eight instances out of a com-paratively small number of rats OIn a double-deficiency diet. After an extensive search throughthe literature of rat-breeding, they had failed to.discover an instance of this occurrence underother conditions. The authors further state thatSteinbock has also reported the birth of macerate(dfcetuses in cattle and swine fed on similar deficiencydiets.

It cannot be questioned that these observations;of Reynolds and Macomber are very suggestive.It is difficult to make tests of sufficient numbersof cases in clinical work, but occasional oppor-tunities may arise of seeking the explanation offailure to conceive, or, after conception, of failureto carry the child to term, in deficiency of someimportant dietetic element. We have all seenthose rare but puzzling cases in which a womanhas on several occasions carried her child almostto term, and then for some quite obscure reasonthe foetus has died in utero before labour has setin. Such cases, of course, are generally syphilitic,but failing this explanation, it would be worthwhile to explore the possibility of a dieteticdeficiency being the operative cause. Occasionalinstances of what used to be called " habitualabortion"' nay also possibly arise from somnedietetic fault.The calcium content of the diet of an expectanit

mother is especially deserving of consideration.Blair Bell has estimated that the mother partswith 800 g. of calcium during the nine months ofpregnancy; unless this element is freely renewe(din the diet, it is quite possible that the fctus maybe calciumn-starved with disastrouis effects to itsvitality. Milk and green vegetables are theprincipal dietetic sources of calcium, and thiselement can, of course, be readily supplemente(dmedicinally.

Effects of Alcohol ona the Foetas.-J do niotwish to raise the vexed question as to whether-* Post-graduate Lecture delivered at the Prinice olf Wales's

General Hospital on July 19th, 1926.

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