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ON THE WALKING VALUE OF THE LESSER TOES OF THE HUMAN FOOT.
1250
fully and forcibly over flexed on to the plantar aspect of the foot. This was readily done without material resiEtance.1 During the six ensuing months mechanical extension on the original plan was pursued, but it soon became evident from the exquisite tenderness of the toes that this method, which answers well enough in simple cases, could only here be intermittent and unsuccessful. Seeing therefore no other alternative and feeling confident that the issue would be t I advocated amputation of all the remaining THE mechanical value of various parts of the human body y satisfactory e- lesser toes of both feet and, having obtained the sanction of is more surely ascertained by actual experiment than prethe patient’s father, I took her to Mr. Augustus Pepper for dicted by theory ; hence whilst it may seem easy enoughhis 1 opinion as to the advantages of the operation. Mr. 88 ] to formulate reasonable explanations of the uses of the toes Pepper’s judgment being also in its favour he, on Nov. 10th, it is only by their separate removal and by observing the i removed all the remaining lesser toes by separate incisions, well on the dorsal aspect of the foot so as to avoid any results that a sound conclusion can be )e kept completely ensuing arrived at. In a work which I wrote in 1885 on the losses !s chance of the cicatrices being involved in the subsequent first intention and within tread. The wounds all healed by amputation of portions of the limbs I endeavoured tothree weeks the patient could bystand on her feet which show with respect to the toes that the great toe with the Ie presented the appearance shown in the accompan)iDg head of its metatarsal bone constituted the real tread of the illustration reproduced from a photograph which I took foot and that if this tread was lost in any way it was best to discard the whole foot as useless and to remove it by Pirogoff’s operation. On the other hand, I asserted that the remaining toes of the foot were mechanically of slight value and that they could be removed one and all with little detriment to the ordinary walking powers. I based these statements on my own experiences of soldiers who had lost portions of their feet from frost-bites or otherwise during the Crimean campaign and whom I afterwards saw as pensioners of Chelsea Hospital. In 1889 Mr. Thomas Ellis of Gloucester published an erudite and instructive manual on "The Human Foot"in which work the following passage occurs : ’’ Here let it be said that the toes play a far more important part in the ordinary functions of the foot than is generally admitted. One sees statements (where better things might be expected) to the effect that their services could be dispensed with. Even in walking, as usually done, they are used much more than is generally supposed. If they were not used the muscles moving them would be found to be wasted." Now as I read Mr. Ellis’s valuable monograph with considerable care and interest, and as this particular opinion expressed by him was somewhat at variance with my own experience, I was in the hope that at some future time a case might arise under my own entire observation which could be appealed to as settling these points of difference, and I think the following instance, from its absolute completeness, may be cited as doing so. The patient was born in 1871. Her history prior to my seeing her was, in her own words, as follows: "At the age of two years I suffered with terrible chilblains, which were so neglected that it was only with the greatest care that the toes were saved. Since then my of them. The subsequent results have been such as to toes have always troubled me. The two little ones began justify the wisdom of the operation and to prove distincto contract when I was ten years old, and this con- tively that the lesser toes are not of the paramount traction caused corns which by the time I was fifteen were value sometimes assigned to them. As the patient lived so bad that they suppurated. I was then under a chiropodist at a distance and as there was no necessity to keep her of Manchester, who used to relieve them, but only for a time. in town for observation I asked her to periodically write to Finally, when they pained beyond all endurance, I went to me reports of her progress and of this the dated extracts a consulting surgeon in Liverpool, who suggested their from her letters will probably form the best record. Dec. 30th, 1894: "Iam able to walk perfectly on tendons being’ cut, and this was done by our own doctor in April, 1892. As this operation proved of no effect my feet with little or no pain, but cannot yet wear in relieving the continuous and excruciating pain, he either slippers or boots as they are still tender. "1895: "I managed to get on my slippers amputated both the little toes in June of the same year Jan. 15th, and wore them with ease for more than six and with immediate relief. The other toes at this time were yesterday " not much affected, but by March, 1893, they also had hours."—Jan. 28th : I put on my boots to-day for the first become contracted, causing me much pain, and finally severe time. It still pains me slightly to walk, otherwise my feet In are going on all right."—Feb. 18th : "II ought to say that corns similar to those formerly on the little toes. of Holt I consulted Mr. Barnard Savile-row, the steel plates only half way answer splendidly."January, 1894, who recommended complete stretching of the tendons under March 24th : "You will be glad to hear that I can walk chloroform and subsequent mechanical extension." Such splendidly now, just like a proper human being; it is just When I first saw eighteen weeks next Tuesday since the operation. "-May 5th : was the patient’s own account of herself. her with Mr. Barnard Holt she was a fine, well-proportioned "II have decided to come to town next Monday week to let girl, with no other trouble with regard to her health than you see how well I can walk."-Jane 17th : "Iplayed two that due to the persistent pain in the toes. With respect to sets of tennis on Saturday, and my feet were none the worse these toes the contraction of the extensor tendons was by no afterwards. "-July 24th : "You will be surprised to hear means spastic, but appeared to be rather accommodative and that the big toes have lengthened in. since the operation, due to an instinctive effort to save them from coming to and I have had all my-boots lengthened and the toe line the ground in walking. The toes themselves were enlarged made straighter."-Aug. 30th: "I know that you will be and bulbous, their surfaces being covered with corny, un- interested to hear that I have iust accented an invitation to healthy skin. Further, they were not only painful whilst in boots, but were also so at night and to such an extent as to 1 It is a melancholy accompaniment to this case that the late Mr. Barnard Holt became in the middle of this slight manipulation frequently prevent sleeping. and the same day he took to his room which he On Feb. 6th (the extension apparatus having been in the suddenly indisposed never left again. The case, therefore, accidentally passed unhappily the was interim prepared) anaesthetised and the toes entirely into my hands. patient were
ON THE WALKING VALUE OF THE LESSER TOES OF THE HUMAN FOOT. BY HEATHER BIGG,
h
’ ,
1251 Whether I shall dance comfortably iis not only attended with some technical difficulty but the thing."—Sept. 14th : "Iwent to the dance iproducts are too unstable and unreliable to become generally Tuesday evening and thoroughly enjoyed myself after not available. Not so those of the second group. These, for the dancing long. My feet were on their best behaviour, most part, are easily obtained, stable, reliable in action and and did not pain me once during the evening. I never economical in price. The best-known examples are maltrealised before that I had no toes until I began to dance, diastase and taka-diastase. Malt-diastase occurs in markedly then it seemed so odd only to have one toe, but I suffered no varying proportions in all extracts of malt (moist and dry), inconvenience whatever from the loss of them."-Dec. 5th : while taka-diastase is prepared by making a cultivation of "get on so well with my bicycle." Eurotium oryzas (of the Aspergillus group) on hydrolysed
a dance on or not is another on for so
Sept.
13th.
It is unnecessary to carry these extracts further : suffice wheat bran. The diastatic influence is extracted with water it to say that the patient has been able to walk, cycle, and separated by evaporation as a scaly powder which is dance, play tennis, and to pursue, in short, every other readily soluble in water and possesses well-marked hydroexercise and amusement which girls of her own age enjoy. lytic power. Many samples were tested against normal As regards the mechanical assistance which it seemed saliva and the following three examples were eventually advisable to give to the tread of the foot during the selected as fair representatives of the second group : (1) healing process it may be stated that with her first boots Kepler’s malt extract (moist) ; (2) Wilcox’s desiccated malt she had a thin steel plate extending the whole length of extract (dry) ; and (3) taka-diastase (dry). These were the foot and lying between the leathers of the sole. tested chemically and clinically. Cliemioal tests.-It must be borne in mind that the conAfter three months these plates were reduced so as to only extend from the instep forwards and before the dition of all test-tube experiments must differ considerably end of the year it was found that the narrow steel spring from normal and morbid digestive changes, and, however beneath the great toe was all that was requisite. These carefully carried out, the results must only be judged as adjuncts to the sole were used to assist the great toe in approximate. The first series of trials were made in order acquiring complete usage to the tread of the foot. Farther, to ascertain which of the preparations possessed the greatest to prevent the foot spreading transversely whilst the tissues amount of diastatic power. It would be tedious to detail at the heads of the metatarsals were consolidating a strip them all, but the following are illustrative and can be of Leslie’s plaster an inch broad was for some time worn done by anyone. First experiment (test-tube): 20 gr. of Mund the foot. malt extract (moist), 5 gr. of malt extract (dry), and Only two disadvantages showed themselves as the result 1 gr. of taka-diastase were mixed respectively with 100 of the operation and these were temporary. One was that minims of a 5 per cent. solution of arrowroot, neutralised the great toes tended to pervert themselves towards the and placed in a water bath at 38° C. At the end of twenty middle line of the feet, a thing which was readily remedied minutes the malt extract gave erythrodextrin and a trace by the use of single-toed stockings and by packing the of maltose; the taka-diastase chiefly maltose and soluble space in the boot left vacant by the missing toes with starch and the desiccated malt chiefly soluble starch. cotton wool ; the other was a loss of local sense on the (Saliva gave soluble starch in excess with trace of maltose.) outer sides of the feet, which went to show that the lesser Second experiment : A thick paste consisting of 3 oz. of toes were missed rather as tactile organs than anything else. arrowroot (representing a full meal of carbo-hydrates) boiled This failure of feeling righted itself in time presumably by with 15 oz. of water, cooled to 40° C. and rendered faintly a vicarious and intenser sense being acquired by the skin of alkaline, was placed in a flask with 300 grains of Kepler’s the outer side of the foot. In all other respects the loss of malt extract, 150 grains of desiccated malt, and 15 grains of the toes discovered no inconvenience. taka-diastase respectively. The flasks were placed in a water There is only this to be added, that whilst the feasibility of bath, kept at a temperature of 38° C., and shaken every three so complete an operation is demonstrated in this particular minutes. At the end of five minutes the Kepler’s malt case it would be needless to resort to it except in rare extract and desiccated malt showed no change, while the instances. Ordinarily contracted toes can be dealt with taka-diastase could readily be shaken, the paste being broken by much less radical measures if the toes themselves be up and about one-third appeared fluid. In ten minutes it sound. Still there are frequent instances in which even was only lumpy in the centre and in thirty minutes the after mechanical extension or division of the tendons the lumps had quite disappeared, while the Kepler’s malt toes revert into their inconvenient position and in such extract and desiccated malt were nearly as gelatinous as at cases amputation can be adopted without scruple. I recall first. It was found that the products of the taka-diastase an instance of a gentleman whose family had an apparently i action were soluble starch, maltose, and erythrodextrin, the hereditary disposition to contraction of the third toe in each ’, original arrowroot being entirely changed while the Kepler’s foot. I took him to the late Mr. Berkeley Hill, who divided malt extract and desiccated malt only afforded small quanthe extensor tendons and the toes were readily straightened, tities of sugar, soluble starch and dextrin. This test indibut after some time they reoontracted ; finally, they were cates that taka-diastase possesses greater hydrolytic power amputated without the slightest detriment to his powers of than either of the malt extracts, which may be due either to walking and the inconvenience was once and for all removed. a higher ferment potential or to a greater range of action This, of course, was only one toe in each foot, but there under disadvantageous and artificial conditions, such as appears no reason why in necessary cases all or any of the al3cumulation of sugar and intermediate products, &c. It lesser toes should not be removed without crippling dis- was further observed that increase of the temperature up to advantages. I believe that the excellent results in the 50° C. increased the action of the malt extract. complete case I have here recorded are largely due to the Having considered the behaviour of these ferments under method Mr. Augustus Pepper adopted of keeping the what might be termed favourable conditions the next point cicatrices clear of the ultimate tread of the feet. was to watch them under morbid influences similar to those Wimpole-street, W. occurring in so-called dyspeptics. During pyrosis, lactic acetic and butyric acids are present in proportions variable yet minute. A sufficiency of each acid was added to starch solutions to produce the well-known acid taste and the AMYLOLYTIC FERMENTS. solutions were then watched under the same conditions of BY WYATT WINGRAVE, temperature as in the other tests. In each case the starch ASSISTANT SURGEON TO THE CENTRAL LONDON THROAT AND EAR was converted after three times the duration of the expoHOSPITAL. soluble starch and sure used in the other tests into to erythrodextrin, but sugar only appeared in slightly THE personal necessity for a starch ferment having very small quantities after three to four hours. The suggested a few experiments with several easily obtainable addition of neutral peptones and proteids did not appear preparations, the experience so gained may possibly prove to exert any influence. The presence of 0’2 per cent. of acid after exposure for twenty minutes perhelpful to others in their selection of a ferment from a group hydrochloric which clinically receives less attention than the proteolytic manently killed all the ferments, but for a less period activity was restored on neutralisation. Quinine dissolved does. in citric acid did not inhibit unless the strength exceeded <7&oMe of ferment.-Starch ferments may be divided into 0’5 per cent., a point which is of clinical interest since my two chief kinds, according to their sources : (a) animal, pre- experience has shown that small doses of 2 gr. to 1 gr. pared from glands-ptyalin (salivary), amylopsin (pancreas) ; undoubtedly act beneficially in cases of pyrosis. The and (b) vegetable or diastatic. The preparation of group a ferments were then tested with raw starch as represented ’)
-
fully and forcibly over flexed on to the plantar aspect of the foot. This was readily done without material resiEtance.1 During the six ensuing months mechanical extension on the original plan was pursued, but it soon became evident from the exquisite tenderness of the toes that this method, which answers well enough in simple cases, could only here be intermittent and unsuccessful. Seeing therefore no other alternative and feeling confident that the issue would be t I advocated amputation of all the remaining THE mechanical value of various parts of the human body y satisfactory e- lesser toes of both feet and, having obtained the sanction of is more surely ascertained by actual experiment than prethe patient’s father, I took her to Mr. Augustus Pepper for dicted by theory ; hence whilst it may seem easy enoughhis 1 opinion as to the advantages of the operation. Mr. 88 ] to formulate reasonable explanations of the uses of the toes Pepper’s judgment being also in its favour he, on Nov. 10th, it is only by their separate removal and by observing the i removed all the remaining lesser toes by separate incisions, well on the dorsal aspect of the foot so as to avoid any results that a sound conclusion can be )e kept completely ensuing arrived at. In a work which I wrote in 1885 on the losses !s chance of the cicatrices being involved in the subsequent first intention and within tread. The wounds all healed by amputation of portions of the limbs I endeavoured tothree weeks the patient could bystand on her feet which show with respect to the toes that the great toe with the Ie presented the appearance shown in the accompan)iDg head of its metatarsal bone constituted the real tread of the illustration reproduced from a photograph which I took foot and that if this tread was lost in any way it was best to discard the whole foot as useless and to remove it by Pirogoff’s operation. On the other hand, I asserted that the remaining toes of the foot were mechanically of slight value and that they could be removed one and all with little detriment to the ordinary walking powers. I based these statements on my own experiences of soldiers who had lost portions of their feet from frost-bites or otherwise during the Crimean campaign and whom I afterwards saw as pensioners of Chelsea Hospital. In 1889 Mr. Thomas Ellis of Gloucester published an erudite and instructive manual on "The Human Foot"in which work the following passage occurs : ’’ Here let it be said that the toes play a far more important part in the ordinary functions of the foot than is generally admitted. One sees statements (where better things might be expected) to the effect that their services could be dispensed with. Even in walking, as usually done, they are used much more than is generally supposed. If they were not used the muscles moving them would be found to be wasted." Now as I read Mr. Ellis’s valuable monograph with considerable care and interest, and as this particular opinion expressed by him was somewhat at variance with my own experience, I was in the hope that at some future time a case might arise under my own entire observation which could be appealed to as settling these points of difference, and I think the following instance, from its absolute completeness, may be cited as doing so. The patient was born in 1871. Her history prior to my seeing her was, in her own words, as follows: "At the age of two years I suffered with terrible chilblains, which were so neglected that it was only with the greatest care that the toes were saved. Since then my of them. The subsequent results have been such as to toes have always troubled me. The two little ones began justify the wisdom of the operation and to prove distincto contract when I was ten years old, and this con- tively that the lesser toes are not of the paramount traction caused corns which by the time I was fifteen were value sometimes assigned to them. As the patient lived so bad that they suppurated. I was then under a chiropodist at a distance and as there was no necessity to keep her of Manchester, who used to relieve them, but only for a time. in town for observation I asked her to periodically write to Finally, when they pained beyond all endurance, I went to me reports of her progress and of this the dated extracts a consulting surgeon in Liverpool, who suggested their from her letters will probably form the best record. Dec. 30th, 1894: "Iam able to walk perfectly on tendons being’ cut, and this was done by our own doctor in April, 1892. As this operation proved of no effect my feet with little or no pain, but cannot yet wear in relieving the continuous and excruciating pain, he either slippers or boots as they are still tender. "1895: "I managed to get on my slippers amputated both the little toes in June of the same year Jan. 15th, and wore them with ease for more than six and with immediate relief. The other toes at this time were yesterday " not much affected, but by March, 1893, they also had hours."—Jan. 28th : I put on my boots to-day for the first become contracted, causing me much pain, and finally severe time. It still pains me slightly to walk, otherwise my feet In are going on all right."—Feb. 18th : "II ought to say that corns similar to those formerly on the little toes. of Holt I consulted Mr. Barnard Savile-row, the steel plates only half way answer splendidly."January, 1894, who recommended complete stretching of the tendons under March 24th : "You will be glad to hear that I can walk chloroform and subsequent mechanical extension." Such splendidly now, just like a proper human being; it is just When I first saw eighteen weeks next Tuesday since the operation. "-May 5th : was the patient’s own account of herself. her with Mr. Barnard Holt she was a fine, well-proportioned "II have decided to come to town next Monday week to let girl, with no other trouble with regard to her health than you see how well I can walk."-Jane 17th : "Iplayed two that due to the persistent pain in the toes. With respect to sets of tennis on Saturday, and my feet were none the worse these toes the contraction of the extensor tendons was by no afterwards. "-July 24th : "You will be surprised to hear means spastic, but appeared to be rather accommodative and that the big toes have lengthened in. since the operation, due to an instinctive effort to save them from coming to and I have had all my-boots lengthened and the toe line the ground in walking. The toes themselves were enlarged made straighter."-Aug. 30th: "I know that you will be and bulbous, their surfaces being covered with corny, un- interested to hear that I have iust accented an invitation to healthy skin. Further, they were not only painful whilst in boots, but were also so at night and to such an extent as to 1 It is a melancholy accompaniment to this case that the late Mr. Barnard Holt became in the middle of this slight manipulation frequently prevent sleeping. and the same day he took to his room which he On Feb. 6th (the extension apparatus having been in the suddenly indisposed never left again. The case, therefore, accidentally passed unhappily the was interim prepared) anaesthetised and the toes entirely into my hands. patient were
ON THE WALKING VALUE OF THE LESSER TOES OF THE HUMAN FOOT. BY HEATHER BIGG,
h
’ ,
1251 Whether I shall dance comfortably iis not only attended with some technical difficulty but the thing."—Sept. 14th : "Iwent to the dance iproducts are too unstable and unreliable to become generally Tuesday evening and thoroughly enjoyed myself after not available. Not so those of the second group. These, for the dancing long. My feet were on their best behaviour, most part, are easily obtained, stable, reliable in action and and did not pain me once during the evening. I never economical in price. The best-known examples are maltrealised before that I had no toes until I began to dance, diastase and taka-diastase. Malt-diastase occurs in markedly then it seemed so odd only to have one toe, but I suffered no varying proportions in all extracts of malt (moist and dry), inconvenience whatever from the loss of them."-Dec. 5th : while taka-diastase is prepared by making a cultivation of "get on so well with my bicycle." Eurotium oryzas (of the Aspergillus group) on hydrolysed
a dance on or not is another on for so
Sept.
13th.
It is unnecessary to carry these extracts further : suffice wheat bran. The diastatic influence is extracted with water it to say that the patient has been able to walk, cycle, and separated by evaporation as a scaly powder which is dance, play tennis, and to pursue, in short, every other readily soluble in water and possesses well-marked hydroexercise and amusement which girls of her own age enjoy. lytic power. Many samples were tested against normal As regards the mechanical assistance which it seemed saliva and the following three examples were eventually advisable to give to the tread of the foot during the selected as fair representatives of the second group : (1) healing process it may be stated that with her first boots Kepler’s malt extract (moist) ; (2) Wilcox’s desiccated malt she had a thin steel plate extending the whole length of extract (dry) ; and (3) taka-diastase (dry). These were the foot and lying between the leathers of the sole. tested chemically and clinically. Cliemioal tests.-It must be borne in mind that the conAfter three months these plates were reduced so as to only extend from the instep forwards and before the dition of all test-tube experiments must differ considerably end of the year it was found that the narrow steel spring from normal and morbid digestive changes, and, however beneath the great toe was all that was requisite. These carefully carried out, the results must only be judged as adjuncts to the sole were used to assist the great toe in approximate. The first series of trials were made in order acquiring complete usage to the tread of the foot. Farther, to ascertain which of the preparations possessed the greatest to prevent the foot spreading transversely whilst the tissues amount of diastatic power. It would be tedious to detail at the heads of the metatarsals were consolidating a strip them all, but the following are illustrative and can be of Leslie’s plaster an inch broad was for some time worn done by anyone. First experiment (test-tube): 20 gr. of Mund the foot. malt extract (moist), 5 gr. of malt extract (dry), and Only two disadvantages showed themselves as the result 1 gr. of taka-diastase were mixed respectively with 100 of the operation and these were temporary. One was that minims of a 5 per cent. solution of arrowroot, neutralised the great toes tended to pervert themselves towards the and placed in a water bath at 38° C. At the end of twenty middle line of the feet, a thing which was readily remedied minutes the malt extract gave erythrodextrin and a trace by the use of single-toed stockings and by packing the of maltose; the taka-diastase chiefly maltose and soluble space in the boot left vacant by the missing toes with starch and the desiccated malt chiefly soluble starch. cotton wool ; the other was a loss of local sense on the (Saliva gave soluble starch in excess with trace of maltose.) outer sides of the feet, which went to show that the lesser Second experiment : A thick paste consisting of 3 oz. of toes were missed rather as tactile organs than anything else. arrowroot (representing a full meal of carbo-hydrates) boiled This failure of feeling righted itself in time presumably by with 15 oz. of water, cooled to 40° C. and rendered faintly a vicarious and intenser sense being acquired by the skin of alkaline, was placed in a flask with 300 grains of Kepler’s the outer side of the foot. In all other respects the loss of malt extract, 150 grains of desiccated malt, and 15 grains of the toes discovered no inconvenience. taka-diastase respectively. The flasks were placed in a water There is only this to be added, that whilst the feasibility of bath, kept at a temperature of 38° C., and shaken every three so complete an operation is demonstrated in this particular minutes. At the end of five minutes the Kepler’s malt case it would be needless to resort to it except in rare extract and desiccated malt showed no change, while the instances. Ordinarily contracted toes can be dealt with taka-diastase could readily be shaken, the paste being broken by much less radical measures if the toes themselves be up and about one-third appeared fluid. In ten minutes it sound. Still there are frequent instances in which even was only lumpy in the centre and in thirty minutes the after mechanical extension or division of the tendons the lumps had quite disappeared, while the Kepler’s malt toes revert into their inconvenient position and in such extract and desiccated malt were nearly as gelatinous as at cases amputation can be adopted without scruple. I recall first. It was found that the products of the taka-diastase an instance of a gentleman whose family had an apparently i action were soluble starch, maltose, and erythrodextrin, the hereditary disposition to contraction of the third toe in each ’, original arrowroot being entirely changed while the Kepler’s foot. I took him to the late Mr. Berkeley Hill, who divided malt extract and desiccated malt only afforded small quanthe extensor tendons and the toes were readily straightened, tities of sugar, soluble starch and dextrin. This test indibut after some time they reoontracted ; finally, they were cates that taka-diastase possesses greater hydrolytic power amputated without the slightest detriment to his powers of than either of the malt extracts, which may be due either to walking and the inconvenience was once and for all removed. a higher ferment potential or to a greater range of action This, of course, was only one toe in each foot, but there under disadvantageous and artificial conditions, such as appears no reason why in necessary cases all or any of the al3cumulation of sugar and intermediate products, &c. It lesser toes should not be removed without crippling dis- was further observed that increase of the temperature up to advantages. I believe that the excellent results in the 50° C. increased the action of the malt extract. complete case I have here recorded are largely due to the Having considered the behaviour of these ferments under method Mr. Augustus Pepper adopted of keeping the what might be termed favourable conditions the next point cicatrices clear of the ultimate tread of the feet. was to watch them under morbid influences similar to those Wimpole-street, W. occurring in so-called dyspeptics. During pyrosis, lactic acetic and butyric acids are present in proportions variable yet minute. A sufficiency of each acid was added to starch solutions to produce the well-known acid taste and the AMYLOLYTIC FERMENTS. solutions were then watched under the same conditions of BY WYATT WINGRAVE, temperature as in the other tests. In each case the starch ASSISTANT SURGEON TO THE CENTRAL LONDON THROAT AND EAR was converted after three times the duration of the expoHOSPITAL. soluble starch and sure used in the other tests into to erythrodextrin, but sugar only appeared in slightly THE personal necessity for a starch ferment having very small quantities after three to four hours. The suggested a few experiments with several easily obtainable addition of neutral peptones and proteids did not appear preparations, the experience so gained may possibly prove to exert any influence. The presence of 0’2 per cent. of acid after exposure for twenty minutes perhelpful to others in their selection of a ferment from a group hydrochloric which clinically receives less attention than the proteolytic manently killed all the ferments, but for a less period activity was restored on neutralisation. Quinine dissolved does. in citric acid did not inhibit unless the strength exceeded <7&oMe of ferment.-Starch ferments may be divided into 0’5 per cent., a point which is of clinical interest since my two chief kinds, according to their sources : (a) animal, pre- experience has shown that small doses of 2 gr. to 1 gr. pared from glands-ptyalin (salivary), amylopsin (pancreas) ; undoubtedly act beneficially in cases of pyrosis. The and (b) vegetable or diastatic. The preparation of group a ferments were then tested with raw starch as represented ’)
-