2. That the missing bone is the first phalanx.-According to this view, the first phalanx and the metacarpal bone have, so to speak, become fused into one bone. Henle,1 quoting Uffelmann, says: "Der Mittelhandknochen des Daumens weder ein eigentlicher Mittelhandknochen noch eine Phalange, sondern ein Repräsentant beider ist."

2

Maclise puts the matter very plainly. He says:-"The metacarpal bone of the thumb is constituted of two ossicles, which have become consolidated. If we class the hindmost ossicle with the other metacarpal bones, the foremost ossicle will represent the first phalanx of the other fingers, and this 1 Hdb. der Anat. des Menschen, pt. 1, S. 261.

2 "Skeleton," Todd's Cyclop. Anat, and Phys., p. 663,

will give three phalanges to the thumb as to the other fingers. It is worthy of notice that the so-called metacarpal bone of the thumb corresponds as to the nucleary deposit with the first phalanx of the finger."

2

The late Professor Allen Thomson 1 observed in several instances an epiphysis at the distal end of the metacarpal bone of the thumb, in addition to the normal proximal epiphysis. Basing on this observation, Windle makes the following statement:-"It seems possible that in this distal epiphysis we may have a structure capable of taking an independent development, and thus of giving rise to a supernumerary phalanx, which in this case would be the first.

It may reasonably be objected that such a hypothesis leaves the question of the proximal epiphysis unsettled, but it should not be forgotten that Thomson has described the occasional presence of a similar epiphysis in the metacarpal bone of the index finger."

3. That the missing bone is the metacarpal.—This view is very clearly put by Struthers, thus: "The facts in comparative osteogony show that the position of the epiphysis is decisive in establishing the view that the bone which is wanting in the human thumb and great toe, and in the internal digit of other five-toed mammals, is the metacarpal and metatarsal, although custom and convenience lead us to apply these terms to the bone which homologically is the proximal phalanx."

My case, it seems to me, bears out the contention that the missing bone is the metacarpal, for the skiagraph shows a perfectly normal first metacarpal bone. The question, however, is one for anatomists to discuss and settle, and I prefer to let the skiagraph speak for itself. Perhaps it may attract the attention of some expert.

The feet have each six complete toes. It will be noticed that the great toes have the normal number of bones, and that the epiphysis of the metatarsal bone is proximal.

The only trace of family deformity I could discover in this case was in the mother, whose great toes showed evidence of commencing bifurcation.

The skiagraphs were kindly taken for me by Dr. George Beatson, C.B.

COAGULATION OF INFANTILE BLOOD.1

BY HUGH HOWIE BORLAND, M.B., C.M., D.P.H.(Camb.), Vaccinator to Glasgow Royal Infirmary; District Physician to the Glasgow Maternity Hospital.

THE practical importance of the coagulation of the blood is so wide in its scope, and the phenomena are so striking, that the subject has attracted some of the most profound thinkers and observers in physiology, pathology, obstetrics, surgery, and medicine. Correlated with it, and not less important, is thrombosis, that conservative principle of nature, without which the primary step of reproduction, as one writer observes, would be fraught with danger, as in the case of the bloodvessels in the ovary when an ovum escapes from the Graafian follicle, or, later on, at full term, when the placenta has been expelled, and the great uterine sinuses are gorged with blood.

The converse of this natural process is occasionally met. with when there is some abnormal condition of the blood or blood-vessels; and, as an illustration of this, there comes. vividly before my mind a scene of some four years ago in the Glasgow Maternity Hospital. A patient had been delivered and the placenta duly expelled, but the bleeding which ensued could not be arrested. It was not an ordinary case of post-partum hæmorrhage. The bleeding could not be stayed, in spite of the adoption of all the routine remedies, and with the aid of everything at hand in the labour room. There was the ceaseless drip, drip of the patient's life blood, which would not be staunched. The blood would not clot, and the poor woman simply faded away as we looked on helplessly, unable to arrest the fatal hæmorrhage. The blood had obviously undergone some chemical or pathological change, producing this dire result. My interest in the negative as well as the positive phase of coagulation is largely due to this case.

The normal time of coagulation of the blood is said to be from three to five minutes after shedding, but it varies somewhat. The observations I have made show the minimum to be, as a rule, not less than four minutes in the case of adults; but in certain conditions, particularly in acute exanthemata

1 Paper read before the Glasgow Eastern Medical Society on 1st April, 1903.

and in various forms of hæmorrhagic diathesis, it is said that the clotting time is markedly increased, and that, indeed, coagulation may remain in abeyance. On the other hand, a distinct acceleration in the clotting compared with the normal may be observed. Wright has shown that the clotting time can be influenced by drugs; thus, calcium chloride and carbonic anhydride raise, whereas citric acid, alcohol, arsenic, phosphorus, and increased respiration diminish the clotting power of the blood.

During the last eighteen months I have made an extended series of observations of infant's blood, with the object of demonstrating that the child's blood, in the early hours of life, shows delay in coagulation compared with the succeeding days. I have been struck with many points of interest in this investigation, which will be referred to further on. The charts which I have made use of clearly prove that, from the first day of life onward, there is an unmistakable and decided increase of coagulability. I am not able to affirm that there is a uniform rate of coagulation of blood for all children of the same age on corresponding days following birth. Obviously, we need not look for this, and for very good reasons; as any given infant's blood depends, not simply on its age, but on the stage of its development (as I have noticed in cases of twins). Thus, the fontanelles are more open in some children than in others, and there is often a retardation of the growth of the blood towards the mature condition. This may arise from congenital debility or inherited diseases, such as tuberculosis or syphilis; so that, under the deleterious influence of these conditions, one child's blood may be no further developed at nine months than another child's at seven or eight months; just as a weak, rickety child's blood may show no further development at three years than that of a strong, healthy child at eighteen months.

In what directions are we to look for an explanation of the increase in the coagulability of infant's blood? I am of opinion that the great factors are the large excess of CO, and the concentration of the blood, accompanied by vigorous respiration. Von Pettenkofer has estimated that a child produces, in proportion to its body weight, nearly twice as much CO, as an adult; and I think this helps to explain how in a few days the infant's blood coagulates so much more rapidly. I have found that the weight and sex of the child have no influence upon the coagulation.

The ages of the children examined ranged from 5 minutes up to 10 days. The time was 6 minutes 10 seconds in the

former, and 4 minutes in the latter. The averages for the different days work out as follows:

I shall refer to some of the cases to illustrate these points.

CASE VII. Child 5 minutes old. The blood from the puncture was very dark violet in colour, resembling venous blood, and exuded very slowly. Coagulation, 6 minutes 10 seconds.

CASE XX. Child æt. 3 days 15 hours. Coagulation took 9 minutes 45 seconds. I noticed that the drop of blood from the ear came very freely, and was obviously less coagulable on the ear than in any previous case. I learned on the day after the experiment that the bleeding from the punctured ear did not cease till eight hours had elapsed; in fact, the house surgeon was called up at one o'clock in the morning on account of bleeding. The child was a female.

As a contrast to this, I take another case.

CASE XXIV. Baby S., æt. 19 hours, very fully developed child. Coagulation, 3 minutes 30 seconds. Coagulation very rapid on the lobe of the ear after puncture. The blood very concentrated and dark in colour. Fresh punctures had to be made to get enough blood for the tubes. It was noted, also, that the blood (after the experiment) formed a hard crust-like clot on the ear, whereas in the baby previously tested, the blood was still oozing after the experiment was over.

To show the influence of a few days of life upon the increase of coagulability of infantile blood, I report 7 cases, viz.:

Coagulation-Time.

6 minutes 30 seconds.
4 minutes.

5 minutes 45 seconds.

3 minutes 45 seconds.